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0 U R N A L OF THE IOWA MEDICAL SOCIETY
JANUARY 1995
STACKS
Special issue on
domestic wiofeaice
A special message from the
AMA president
9
Finding the right words —
advice on talking to victims
2 2
Why victims stay in
abusive relationships —
the dynamics of
power and control
2 4
A survivor's story
2 6
Who are the batterers?
2 8
The effects of domestic
abuse on children
3 3
Test your knowledge of
domestic abuse issues
(survey of Iowa
physicians )
C E N I E R INSERT
HEALTH SCIENCES LIBRARY
UNIVERSITY OF MARYLAND
BALTIMORE
JAN 20 1335
1EGU NQT IN CIRC,
Break
the
Silence
Begin the Cure
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Jeff Towle
Financial Consultant
Call 1-800-937-0231
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400 Locust Street, Suite 600
Des Moines, Iowa 50309
Merrill Lynch
A tradition of trust.
©1994 Merrill Lynch, Pierce, Fenner & Smith Inc. Member SIPC.
JANUARY , 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•AN ARTICLE IN THE DECEMBER IOWA MEDICINE Medical Economics section stated an incorrect
amount of total Medicare benefit payments coming into Iowa during 1993. During fiscal year
1993, $1.3 billion was paid for 469,081 Iowa Medicare enrollees. For the same period, the
state of Colorado collected $1.42 billion in benefits for 396,453 enrollees. For a complete
state-by-state listing, call Donna Bottorff at the IMS, 800/747-3070.
•ESTABLISHMENT OF A STATEWIDE TRAUMA SYSTEM will be supported by the Iowa Medical
Society in this year's Iowa Legislature (see page 14 of this Iowa Medicine) . Any physician
who wants more information about the statewide system proposed by the Iowa Trauma Systems
Development Project Planning Consortium is urged to call Thomas Foley, MD, 515/752-6391 or
Tim Peterson, MD, 515/224-6440. For copies of the Consortium report, call Dick Harmon, Iowa
Department of Public Health, 515/281-3741.
•THE 11th ANNUAL INTERNATIONAL SYMPOSIUM ON CREATION OF Electronic Health Record Systems
and Global Conference on Patient Cards will be held March 14-19 at the Disney Contemporary
Resort in Orlando, Florida. For more information on the conference, call Donna Bottorff of
the IMS Staff, 800/747-3070.
•DON'T MISS THE IOWA TELEMEDICINE CONFERENCE "The Future is Now" Monday evening,
January 9 from 7:00 p.m. to 9:30 p.m. The program is designed for physicians, nurses and
others. Cosponsored by the IMS, U of I College of Medicine and others, the program will
cover what telemedicine can do for providers, how much equipment will cost and reimburse-
ment issues. The program can be seen at 54 different sites around Iowa. For information
about the site in your area, call Lyn Durante at the IMS, 800/747-3070.
•THE IMS ELECTION PROCESS is beginning with district caucuses to be held around the
state this month and in February. At each caucus, physicians will choose a representative
and an alternate to the 1995 Nominating Committee. This committee will hold a telephone
conference March 12 to compile a slate of candidates. The caucus schedule can be found on
page 12 of this issue.
•THE IOWA INSURANCE DIVISION is delaying implementation of administrative rules concern-
ing employee health care access under Senate File 2282 passed by the legislature last year.
The new rules — which are being revised to clarify confusion as to the exact requirements
for employers — probably won't go into effect until some time in late February.
•TO GET A COPY OF THE FEDERAL REGISTER which contains information regarding Iowa's des-
ignation as a single Medicare payment locality with one fee schedule, updated RBRVS and
1995 Medicare payment policies: (credit card order) 202/512-1800; (fax order) 202/512-2250;
or write to: New Orders, Superintendent of Documents, PO Box 371954, Pittsburgh, PA 15250.
The price is $8, stock number 069-001-000-81-5.
•THE AMA EXPRESSED CONCERNS ABOUT PROPOSED MEDICARE CUTS in a letter from James Todd,
MD, AMA executive vice president, to President Clinton. According to the letter. Medicare
reimbursement of physicians accounts for only 23% of Medicare expenditures, yet physicians
have been subjected to 40% of provider cuts. The AMA is proposing examination of premium
levels and deductibles and an income related sliding scale for beneficiary cost sharing.
For more information about any deadline news item, call Chris Clark at
IMS headquarters, 515/223-1401 or 800/747-3070.
Iowa
Medicine
About the Cover
It is estimated between
20,000 and 44,000 Iowa
women are battered by
their intimate partners
each year. This issue
and the February issue
of Iowa Medicine are
devoted to educating
physicians on how to
help victims. The logo
on the cover was
designed by IMS
Alliance President
Barbara Bell.
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: $25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission, KS
66215, phone 913/888-
8781. IOWA ADVERTIS-
ING: Jane Nieland, Iowa
Medicine, 1001 Grand
Avenue, West Des Moines,
Iowa 50265. Phone 515/
223-1401. EDITORIAL
CONTENT: The Society is
unable to assume responsi-
bility for the accuracy of
that which is submitted.
Manuscripts or editorial
inquiries should be
directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
JANUARY 1995 / VOLUME 85 / 1
Editorials
Watch for red flags
Every Iowa physician should be on the lookout for signs of domestic
violence in their patients.
0 The Presides! Comments
Give the gift of hope
The American Medical Association president has a message for Iowa
physicians regarding ethical responsibilities and domestic violence.
0 Robert McAfee , MD
fl mass media reality check
Should the media accept a share of responsibility for the explosion of
violence in America? The IMS Alliance president says yes.
# Barbara Bell, IMSA President
Current Issues
12 In the news
12 IMS Update
• District caucus schedule, award nominees sought
13 Futures
• AMA concerned over possible Medicare cuts
14 Legislative Affairs
• IMS will support definition of surgery legislation
15 Medical Economics
• Runner-up gets Medicaid contract; IFMG officer slate
17 Practice Management
• E & M Coding revisions
19
Newsmakers
• Letter to the editor, awards
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
21
Test your
knowledge of
domestic
violence
issues . . .
Don’t miss the
survey of Iowa
physicians in
the center of
this Iowa
Medicine
Science
33
e Articles
Break the silence, begin the cure
Seventy-five percent of partner battering victims seek treatment for immediate or
long-term effects of abuse. However, these victims are hardly ever identified. The
articles on the following pages are designed to give Iowa physicians information
they can use in their practices.
Finding the right words
Experts in partner battering offer excellent advice on how to talk to victims.
Why do they stay?
Victims of domestic violence often take years to leave the abusive relationship. A
counselor discusses the insidious dynamics of power and control. % Kay Maher-Sharp
A survivor’s story
During her 12-year marriage, she was degraded, stalked and nearly beaten to death.
Now she’s putting her life back together. % Christine Clark
Who are the batterers?
A counselor with the Polk County Domestic Abuse Intervention Service discusses
common characteristics of abusers. # D.ale Chell
and Education
A child’s perspective
The author discusses the effects of domestic violence on children.
% Dower Dewdney, MD
Behavioral “repertoires” common to batterers. % Truce Ordona, MD
37 The Editor Comments
39 Physician Learner
Editorial Board
IMS President
James White, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine Clark
Production/Advertising
Manager
Jane Nieland
All articles published
in Iowa Medicine
are listed in
Index Medicus
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-562-2218
Des Moines: 515-245-4688
Iowa
Medicine
About the Cover
This is the second of
two issues devoted to
domestic violence. The
poem on the cover was
written for the Clothes-
line Project of the Polk
County Family Violence
Center.
FEBRUARY 1995 / VOLUME 85 / 2
Editorials
55
57
The AMA in action
Managed care and other issues received attention at the AMA’s Interim
Meeting in December.
% Tin: Presiden t Comments
North Iowa responds to domestic violence
A member of the IMS Alliance discusses a local community approach to
the problem of domestic violence,
w M wise Brixkmax, RN
Current Issues
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission, KS
66215, phone 913/888-
8781. IOWA ADVERTIS-
ING: Jane Nieland, Iowa
Medicine, 1001 Grand
Avenue, West Des Moines,
Iowa 50265. Phone 515/
223-1401. EDITORIAL
CONTENT: The Society is
unable to assume responsi-
bility for the accuracy of
that which is submitted.
Manuscripts or editorial
inquiries should be
directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
In the news
5 8 IMS Update
• IMS represented at AMA meeting
• Domestic abuse panel at IMS Scientific Session
6 0 Futures
• Medicare conversion factors are good news
• Iowa GPGIs increase
6 2 Legislative Affairs
• Any willing provider legislation
• How to contact your legislators
6 4 Medical Economics
• More legal action in mental health contract
• Want to sound off on RBRVS? Here’s how
6 6 Practice Management
• December graduates of the MEP
6 8 Newsmakers
• New members, awards, obituaries
FEBRUARY, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•THE IMS CHMIS COMMITTEE is recommending adoption by the IMS House of Delegates of a
"statement of principles" to guide IMS participation in development of the Iowa Community
Health Management Information System. These principles will ensure that physician interests —
including concerns about confidentiality and ethics — are fairly represented. For more
details about the recent meeting of the IMS CHMIS Committee, see the March Medical Economics
section in Iowa Medicine .
•an ANALYSIS OF THE REPUBLICAN "CONTRACT WITH AMERICA" in the context of AMA policy is
available by calling Chris Clark at IMS headquarters, 515/223-1401 or 800/747-3070.
•FOR THE LATEST ON THE GEOGRAPHIC PRACTICE COST INDICES (GPCIs) for Iowa physicians,
turn to this month's Futures section on page 60. You will also find information on the 1995
Medicare Conversion Factor published in a recent Federal Register.
•SOME OF YOU WHO ATTENDED THE IMS FUTURES CONFERENCE last October expressed an interest
in a book on capitation written by Bill DeMarco, one of the conference speakers. According
to DeMarco, the book is in the final editing stage and will be completed in about a month.
•THE PRICE OF PHYSICIAN SERVICES AS MEASURED BY THE Consumer Price Index increased 4.4%
during the 12 months from December, 1993 -December, 1994. This was the lowest December-to-
December change since 1973.
•IOWA MEDICAL SOCIETY LEADERSHIP has approved a blueprint for specialty society repre-
sentation in the IMS House of Delegates . The blueprint and amended bylaws will be submitted
to the IMS House of Delegates in April. If adopted, specialty societies who meet the cri-
teria will be eligible to participate in the 1996 IMS House of Delegates.
•a STATE DATA CONFERENCE is planned for Thursday, April 6 in Des Moines. The purpose of
the conference is to explore options and develop a state health data strategy. CME credit
will be available. For more information, call Barb Heck at the IMS, 800/747-3070.
•PHYSICIANS ARE ADVISED THAT SOME IOWA NEWSPAPERS have unknowingly published a press
release which attempts to charge consumers $9.95 for government booklets on Medicare which
can actually be obtained for free. The press release, entitled "New Medicare Publications
Now Available", advertises the Medicare 1994 Handbook and the Guide to Health Insurance.
These publications and others may be obtained FREE by writing to: Medicare Publications,
Health Care Financing Administration, 6325 Security Boulevard, Baltimore, Maryland, 21207.
For a list of free Medicare publications available for consumers, call Chris Clark at the
IMS, 800/747-3070 or 515/223-1401.
•A 3 -DAY SEMINAR ON SPECIALTY CODING by nationally-known coding expert Nancy McGuire
will be sponsored by the Iowa Medical Society Tuesday-Thursday , April 18-20, in Des Moines.
The seminar will cover coding for primary care, neurosurgery, orthopedic surgery, ENT,
pediatrics and others. You will receive a mailing on this special seminar.
•medicare PHYSICIAN PARTICIPATION RATES FOR 1995 should be available by mid-February when
the 1995 MEDPARD book is released. The MEDPARD is mailed to all participating physicians.
For more information, call Barb Heck at the IMS, 515/223-1401 or 800/747-3070.
For more information about any deadline news item, call Chris Clark at
JOURNAL OF THE IOWA MEDICAL SOCIETY
Feature A r t i c l e s
Domestic violence: the law and physician liabilities
A Des Moines attorney discusses physician reporting responsibilities under Iowa
law and commonly asked questions regarding patient consent and legal protections.
% Jeanine Freeman, JD
An insert
for your
patients . . .
Look in the
center of
this Iowa
Medicine.
Extra copies
available by
calling Jane
Nieland at
the IMS.
Science
Documenting domestic abuse
An Iowa police officer gives advice on medical record and photographic
documentation of domestic abuse. £ Curtis Ruby
Rural battered women
Limited access to a telephone, a means of transportation and the court system are some
of the special problems faced by battered women in rural Iowa. 0 Laurie Schirper
Domestic violence programs across Iowa
A map and other referral information for physicians across the state.
What works, what doesn’t work
Iowa physicians offer advice on how to deal with victims in your office.
and Education
Iowa domestic abuse scenarios
What choice would you make in these situations?
# Lee Fagre, MD; Kathleen Buckwalter, RN
Laparoscopic splenectomy
0 Warren Bower, MD: David Coster, MD; Mark Westberg, MD; Victor
Wilson, MD
89 The Editor Comments
9 1 Physician Learner
Editorial Board
IMS President
James White, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Iluston
Managing Editor
Christine Clark
Production/Advertising
Manager
Jane Nieland
All articles published
in Iowa Medicine
are listed in
Index Medicus
STATEWIDE
PHYSICIANS
HEALTH
Over 10,000 individuals are protected by the Iowa
Medical Society-sponsored STATEWIDE PHYSICIANS
HEALTH INSURANCE PROGRAM. It’s stable cover-
age with competitive rates.
If you're not one of the SPHIP insureds, you may want
to explore the program’s many coverage options —
both medical and dental. We’ll be glad to supply
information specific to you and your practice.
Endorsed and overseen by the IMS for its members,
their families and employees, the SPHIP has been
underwritten by Blue Cross Blue Shield of Iowa
since the program began 40 years ago. Today’s
program incorporates various deductibles and cover-
age formats.
Please call Ruth Clare, Terri DeGroot or Mary Sievers
for information about the program.
BERNIE LBWE 5c A55BEIATE5. INE.
Insurance Administrators to Professional Associations &
Universities and Colleges
515-222-BB11 1-BDB-942-471B FAX 515-222-B915
27 BD Westown Parkway. Suite 41B
\A/f=><=t- rif=»t; \/1ninc3c= ln\A/4 Rn^RR-l^ll
Iowa Medicine
Iowa Medicine
About the Cover
Lois Stoltze, MD, an
anesthesiologist at
McFarland Clinic in
Ames, checks on a
patient before surgery.
MARCH 1995 / VOLUME 85 / 3
Editorials
Exciting times
Communities all over Iowa are pursuing dramatically different ways
of providing health care. % The President Comments
King Will and the Foul Humours
Don’t miss this wonderfully satirical Fable for Health System Reform
which brought down the House of Delegates at the AMA’s Interim
Meeting in December. # Robert McAfee, MD, president, AMA
Current Issues
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: $25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
In the news
112 IMS Update
• IMS House of Delegates April 28-30, Des Moines Marriott
• Specialty society update
113 Futures
• Patient-physician relationship at risk, says JAMA article
• AMA calls for Medicare reform
• Is Congress really serious about cutting the budget?
115 Legislative Affairs
• Insurance, liability reform introduced in Iowa Legislature
• AMA legislative priorities
117 Medical Economics
• IMS committee recommends CI1MIS policy
• Medicaid managed care plan awash in lawsuits
119 Practice Management
• You asked for it, we have it . . . coding extravaganza
• HCFA documentation guidelines
1 2 1
Newsmakers
MARCH, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•VIDEOTAPES OF THE JANUARY TELEMEDICINE CONFERENCE cosponsored by the Iowa Medical
Society are now available. Two different videotapes are available — one of the entire pro-
gram and one depicting a fiberoptics consult between physicians in Des Moines and Fort
Dodge. Call Becky Roorda or Lyn Durante at the IMS, 515/223-1401 or 800/747-3070.
•THE IOWA MEDICAL SOCIETY WAS MENTIONED IN A RECENT Des Moines Register article on
possible reinstatement of the death penalty in Iowa. IMS President James White, MD comment-
ed on IMS and AMA ethical policy which forbids physician participation in state executions.
For a complete explanation of IMS/AMA policy on capital punishment, see the April Iowa
Medicine.
•APPARENTLY, THERE'S TROUBLE IN MINNESOTA as Minnesota House and Senate Republicans have
announced a plan to dismantle several aspects of the much-touted health care reform plan,
MinnesotaCare, including the 1997 deadline for achieving universal coverage and community
rating. Iowa physicians were recently part of a successful lawsuit against the state of
Minnesota over a 2% provider tax assessed against out-of-state physicians treating
Minnesotans. A judge ruled the tax unconstitutional for out-of-state providers; the state of
Minnesota has decided not to appeal .
•a RECENT WALL STREET JOURNAL ARTICLE described the AMA's new Physician Capital Source
Program, which Iowa physicians learned about during last October's Futures program in Des
Moines. The Journal said the AMA's project "will give doctors business skills and introduce
them to sources of capital so they can compete against insurers and investor-owned HMOs
dominating the health care landscape" . For more information about the program, call the AMA
Managed Care Hotline, 800/AMA-1066 .
•THE IOWA FOUNDATION FOR MEDICAL CARE is beginning a new project which will involve 100
Iowa physicians. The Ambulatory Care Quality Improvement Project is a multi-Peer Review
Organization pilot cooperative project which will focus on improving care in physician
offices for Medicare patients with diabetes mellitus. The project will promote physician
self-examination. IFMC is sending letters to a randomly-selected group of physicians
requesting their participation. You may volunteer for this project by calling Peg Mason at
IFMC, 800/383-2856.
•THE IMS /IOWA STATE BAR ASSOCIATION REGIONAL MEETINGS will be held Tuesday, March 14 in
Des Moines; Tuesday, March 21 in Sioux City and Monday, March 27 in Cedar Rapids. The pro-
gram will focus on end-of -life/ futile care and sexual harassment in the health care work-
place. For more information on attending, call Tina Preftakes at the IMS, 800/747-3070.
•SF 84, INDIVIDUAL INSURANCE REFORM, has passed both the Iowa House and Senate and is
on its way to the Governor for signature. Key provisions include: limiting rate variations
for blocks of business and prohibiting use of rating characteristics other than age, geo-
graphic area and family composition; disclosure required to prospective customers of provi-
sions related to preexisting conditions; renewal of policies is required unless premiums
have not been paid or the company discontinues business; coverage must be made available to
eligible individuals within 30 days of another policy being discontinued; restrictions on
coverage for preexisting conditions may not be for more than 12 months. Standards for plans
will be set by the insurance commissioner.
For more information about any deadline news item, call Chris Clark at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
122
S C I E N C
127
Advert
e Article
Pitfalls of integration
The decision to integrate should be made only after a thorough
analysis of what the physician has to gain and the potential risks.
# Robert Krypel, JD
and Education
Antibiotic resistance: an emeigency we can’t ignore
As bacteria adapt to their changing environment, the effects of
antibiotic resistance will be increasingly felt by Iowa physicians and
their patients. # Stephes Ri\derk\eciit , DO
129 The Editor Comments
131 The Art of Medicine
ising Directory
132 Classified Advertising
136 Professional Listing
138 Advertising Index
Editorial Board
IMS President
Janies White, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine Clark
Production/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
li'/MERCY
H ° S P 1 T A L Mercy Hospital Medical Center
MEDICAL J H
CENTER preienti
"TRAUMA AND CRITICIAL CARE: CLINICAL PROBLEMS IN THE 90s"
Wednesday, April 12, 1995
Guest Faculty Topics
John Weigelt, M.D "Preoperative Use of Antibiotics:
Chairman, Department of Surgery New Ideas for an Old Idea"
St. Paul-Ramsey Medical Center
St. Paul, Minnesota "Looking at Liver Trauma"
Brent Krantz, M.D "Treatment of Pelvic Fractures"
Director, Trauma Services
Merit Care Medical Center "Trauma Evaluation and Resuscitation"
Fargo, North Dakota
Neil Yeston, M.D "Management of the Intensive Patient:
Professor of Surgery Adult Respiratory Distress Syndrome"
University of Connecticut
College of Medicine
Hartford, Connecticut
Approved by Mercy Hospital Medical Center, an . Physician Fee $50.00
IMS-accredited CME organization for 4 hours of . Physician Assistant $25.00
Category I AMA Physician’s Recognition Award. . Nurses $25.00
Nursing Personnel $25.00
Nursing CEUs: 0.5 (5 Contact Hours) . Pharmacists $25.00
Application has been made for additional accredita- . Paramedicals $25.00
tions. See brochure. Resident/Student Complimentary
This seminar will be held at the Mercy Education Center, Fifth Street and University Avenue,
Des Moines, Iowa. Parking adjacent to the Education Center.
Please contact: Department of Medical Education • Mercy Hospital Medical Center
400 University • Des Moines, Iowa 50314-3190 • 515-247-3042
Iowa Medicine
Iowa Medicine
About the Cover
Juan Harding , MD, a
family practice
physician in Marengo,
explains a chest x-ray
to patient Dawn
Weldon. Using a
computer and a
telephone, the hospital
is able to transmit
x-rays to the U1
Department of
Radiology. Photo by
David Pedersen.
APRIL 1995 / VOLUME 85 / 4
Editorials
Helping our patients and communities
The IMS Education Fund helps physicians and the public and would
not exist without your generosity. 0 The President Comments
Ul College of Medicine in the 21st century
The new dean of the UI College of Medicine discusses his vision for
the future and the leadership challenges he faces.
# Robert Ketch, MD
Current Issues
Iowa Medicine, Journal ot
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
he directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
148 In the news
1 4 8
1 5 0
1 5 2
15 4
15 6
1 5 8
IMS Update
• Policy resolutions submitted for House approval
• Slate of candidates for IMS offices
Futures
• Entitlements threaten future, say ISU economists
• Update on managed care developments
• AMA Capital Source program
Legislative Affairs
• Important bills survive funnel in Iowa Legislature
• IMS/AMA policy on capital punishment
Medical Economics
• CIIMIS activities
• Vaccine for Children program begins
Practice Management
• Coding extravaganza April 18-20
• Brush up on your TB procedures
Newsmakers
144 Iowa Medicine Volume 85/4 April 1 9 95
APRIL, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•THE IMS BILL ON STATUTE OF LIMITATIONS has passed the Iowa House, but its fate in the
Senate is uncertain. Physicians should contact their Senators immediately and ask them
to support HF 394! The bill passed the House on Monday, March 27 on a vote of 71 - 24. The
bill would reduce the statute of limitations for minors so the normal two-year statute would
begin at age 6. In effect, this means a lawsuit for an alleged birth or early childhood
injury would need to be filed by the child's eighth birthday. Ninety-seven percent of law-
suits for birth injuries are brought within this time period; the bill would encourage the
remainder to be filed earlier when witnesses are still available, memories are clearer and
the standard of care prevailing at the time clearly established.
Representatives who voted for the IMS bill to reduce the statute of limitations are:
Democrats — Baker, Mascher, Bell, May, Drees, Mertz, Mundie, O'Brien, Running, Weigel;
Republicans — Arnold, Blodgett, Boddicker, Boggess, Bradley, Branstad, Brauns, Brunkhorst,
Carroll, Churchill, Coon, Corbett, Cormack, Cornelius, Daggett, Disney, Drake, Eddie, Ertl,
Garman, Gipp, Greig, Greiner, Gries, Grubbs, Grundberg, Hahn, Halvorson, Hammitt, Hanson,
Harrison, Heaton, Houser, Huseman, Jacobs, Klemme, Kremer, Lamberti, Larson, Lord, Main,
Martin, Metcalf, Meyer, Millage, Nelson B, Nutt, Rants, Renken, Salton, Schulte, Siegrist,
Sukup, Teig, Tyrrell, Van Fossen, Vande Hoef, Veenstra, Weidman, Welter, Van Maanen.
(Please remember to thank your representatives who voted for the bill)
Representatives who voted against the IMS bill to reduce the statute of limitations are:
Democrats — Bernau, Burnett, Cataldo, Cohoon, Connors, Doderer, Harper, Holveck, Jochum,
Koenigs, Kreiman, Larkin, McCoy, Moreland, Murphy, Myers, Nelson L, Ollie, Schrader, Shoultz,
Warnstadt, Wise, Witt; Republicans — Hurley.
•ALSO IN THE IOWA LEGISLATURE, SF 449, initiated by the Iowa Chiropractic Society,
which would have prevented managed care plans from using physician gatekeepers for chiro-
practic and podiatric services, failed to emerge from the Senate Human Resources Committee.
However, it could appear as an amendment to another bill. SF 339, introduced by the Iowa
Optometric Society, would require all managed care plans to reimburse any optometrist if
such services are covered by the plan. The IMS asks that you call or write your senator
and representative and ask them to oppose all any willing provider bills. These bills make
it impossible for physicians in managed care arrangements such as an IPA or PHO to control
costs and pick partners.
•MEANWHILE, THE AMA IS CELEBRATING A BIG VICTORY following a major victory on the lia-
bility reform front. After intense AMA physician lobbying, the Republican- control led House
voted to limit pain and suffering damages in medical malpractice cases to $250,000. The
medical liability amendment is part of a broader product liability bill. According to the
AMA, every lawmaker was contacted.
•if YOU HAVEN'T READ YOUR MARCH MEDICARE INFO describing Medicare's April 1 Part B com-
puter conversion, the IMS advises you to do so immediately! There will be a noticeable
disruption in cash flow during the conversion. Around March 25, providers should have
received three times their normal payment. From April 4 - April 16, claims will be paid
daily. However, on April 17, the "hold file" requirement will be reinstated, meaning normal
cash flow is not expected again until mid-May. If you have questions, please call Barb
Heck or Mary Reinsmoen of the IMS staff.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
164
166
S C I E N C
171
Advert
e Articles
A new course for medical education
The undergraduate curriculum at the LTniversity of Iowa College of
Medicine has been revamped to put more emphasis on community-
based primary care. % Petek Densen, MD
Hie future of vaccines
The usefulness of antibiotics has become more limited; UI experts
believe the preventive potential of vaccines may be a solution.
# Vera Dordick
a n d Education
Sports medicine education in the U.S.
The authors discuss problems which arise when sports medicine
advice and services do not come from medical professionals.
# Daniel Pick, MD; David Tearse, MD
17 3 The Editor Comments
175 The Physician Learner
ising Directory
176 Classified Advertising
18 0 Professional Listing
182 Advertising Index
Editorial Board
IMS President
James White, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Iluston
Managing Editor
Christine McMahon
Production/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
The Throckmorton Surgical Society
Spring Meeting
IOWA METHODIST
MEDICAL CENTER
Surgical Symposium on
CONTROVERSIES IN SURGERY
AN IOWA HEALTH SYSTEM AFFILIATE
April 21-22, 1995
Iowa Methodist Medical Center • Jester Auditorium
Des Moines, Iowa
SURGICAL
SOCIETY |>
Blake Cady, M.D.
Professor of Surgery
Harvard Medical School
Boston, Massachusetts
Guest Faculty
Maureen Martin, M.D.
Associate Professor of Surgery
Director of Organ Transplantation
University of Iowa
Iowa City, Iowa
Richard M. Devine, M.D.
Assistant Professor of Surgery
Department of Colon/Rectal Surgery
Mayo Clinic School of Medicine
Rochester, Minnesota
Topics
John H. Ranson, M.D.
Professor of Surgery
New York University Medical School
New York, New York
Jon A. vanHeerden, M.D.
Professor of Surgery
Mayo Clinic School of Medicine
Rochester, Minnesota
“Management of Metastatic Liver Disease”
“Diagnosis and Treatment of Primary Hyperparathyroidism”
“Current Evaluation and Treatment of Acute Pancreatitis”
“Diagnosis and Management of Post-Cholecystectomy Injuries”
“Hypercortisolism — What the Surgeon Should Know”
“Role of Axillary Dissection in Early Breast Cancer”
“Evaluation of Thyroid Nodules”
“Timing of Surgery in Gallstone Pancreatitis”
“In Situ Breast Cancer — the Role of Radiotherapy”
“Role of Preoperative Radiation Treatment in Rectal Cancer”
“Laparoscopic Colectomy”
Accreditation
As an organization accredited for Continuing
Medical Education, the Iowa Methodist Medical
Center certifies that this offering meets the
criteria for Category I credit toward AMA
Physician’s Recognition Award, provided it is
used and completed as designed:
Friday, April 21, 1995 7 hours
Saturday, April 22, 1995 3 hours
Cost
Physician fee $150.00
Resident fee $35.00
Contact
Department of Surgery Education
Iowa Methodist Medical Center
1221 Pleasant Street, Suite 550
Des Moines, Iowa 50309; 515/241-4076
Fax: 515/241-4080
Iowa Medicine
Iowa Medicine
About the Cover
Greg Paulson, MD, an
internist with Medical
Associates in Dubuque,
visits with Howard
Martensen on the
skilled nursing unit at
Mercy Health Center,
Dubuque. Photo by
James Shaffer
courtesy of Mercy
Health Center.
MAY 1995 / VOLUME 85 / 5
Editorial
Farewell advice
In his final column as IMS president, Dr. White emphasizes the need
for Iowa physicians to stay informed and stay involved.
# The President Comments
Current Issues
192 In the news
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S 25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
1 9 2
19 4
196
19 8.
200
2 0 1
IMS Update
• Specialty society update
• AMA-ERF Doctors’ Day contributors
Futures
• Managed care statistics for Iowa
• Scorecard of Iowa reforms
• Gingrich calls for investigation
Legislative Affairs
• Which bills survived the second legislative funnel?
• AMA scores liability victory in Congress
Medical Economics
• IMS CIIMIS Committee discusses policy
• Ambulatory Care Quality Improvement Project
Practice Management
• Special cost reductions on seminars
• Discussing bad outcomes with patients
Newsmakers
MAY , 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•THE IMS AND IOWA HOSPITAL ASSOCIATION HAVE BEEN WORKING with representatives of Heritage
National Healthplan, Blue Cross Blue Shield and Principal Health Care on a cooperative agree-
ment regarding the AMA's Patient Protection Act. Under the cooperative agreement, the partic-
ipating organizations would agree to the principles in the Patient Protection Act which pro-
tect patients and physicians under managed care. A draft of the agreement has been prepared
and is under consideration by the various entities . The final agreement will be published in
a future issue of Iowa Medicine.
•THE IMS HEADQUARTERS OFFICE now has phone mail. The new system allows physicians to
call in before and after hours and leave a message with the automated attendant recording.
Callers will need a touchtone telephone to use the directory system. Callers will also have
a choice of leaving a message with a staff member by dialing his or her extension. The
automated attendant recording offers an option at the end for the caller to press 1 and
enter the last name of the person they are trying to reach (if you don't know the staff
person's extension number). A directory of IMS staff extension numbers will appear in the
June Iowa Medicine.
•dr. JAMES TODD, EXECUTIVE VICE PRESIDENT OF THE AMA since 1990, announced in April that
he will retire as AMA EVP at the end of his current contract in June of 1996. He announced
his decision at this time to allow the Board of Trustees ample time to carry out an order-
ly search process and transition. Dr. Todd said he made his decision because a major por-
tion of the agenda he set for himself has been accomplished, including "a change in the
style of interaction the organization brings to its external relationships and to leave the
AMA well-positioned for the future" .
•THE IMS SERVICES CODING EXTRAVAGANZA has been rescheduled for June 13 and 14 at the
Best Western Des Moines International, Des Moines. See the insert to this Iowa Medicine for
additional details .
•1,100 PHYSICIANS AND MEDICAL SOCIETY EXECUTIVES attended the AMA Leadership Conference
in Washington, DC. The Iowa delegation met with four representatives and both Iowa sena-
tors. At this time, all of the Iowa congressmen appear to be opposed to future Medicare
cuts and are concerned about what they could mean to Iowa's elderly. There is a consensus
that very little will be done in the area of health system reform this year.
•A "DIRECT ACCESS TO CHIROPRACTORS" amendment was filed from the floor to SF 484, the
administration appropriations bill . The amendment would prohibit a managed care plan from
using an MD or DO as a gatekeeper for a chiropractor. It passed the Senate April 24; its
fate in the House was uncertain as of press time.
•THE DEPARTMENT OF HUMAN SERVICES plans to implement managed care for Title XIX sub-
stance abuse cases on September 1, 1995. The state has asked for bids from contractors.
•BEGINNING OCTOBER 1, there will be new certification of medical necessity forms which
physicians are required to sign for Durable Medical Equipment. CIGNA staff believe the new
forms will streamline the process, though DME suppliers have launched an aggressive cam-
paign against the new forms. For more information, call Barb Heck at the IMS.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
202
S C I E N C
209
Advert
Article
Financing of physician ventures
Physicians often face major obstacles in securing appropriate
financing for managed care ventures. The author discusses how to
obtain financing and what it takes to be successful. Information on
the AMA’s new Capital Source Program can be found on page 206.
# Steve DeNelsky
and Education
Hepatitis B vaccination: a cost analysis
The authors discuss universal infant immunization from clinical
and economic perspectives.
# George Bergus, MD; Steven Meis, MD
213 The Editor Comments
215 The Art of Medicine
ising Directory
216 Classified Advertising
2 2 0 Professional Listing
2 2 2 Advertising Index
Editorial Board
IMS President
James White, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Production/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
WHO ARE WE?
The Iowa Medical Group Management Association is a nonprofit organi-
zation whose membership is comprised of individuals engaged in the
administrative aspects of medical group practice. Our membership is
diverse, representing group practices operating under various organiza-
tional and financial structures. Current membership in IMGMA includes
over 500 people representing almost 3,500 physicians.
WHO CAM BELONG?
There are four classifications of members: active, affiliate, honorary and
life. Active membership is limited to persons who are serving in an
administrative capacity within a physician group practice, with the
exception of honorary, life and affiliated members. Affiliate members
are individuals who supply products or services to IMGMA members.
WHY JOIN IMGMA?
1 IMGMA enhances your professional growth, development and
viability as a medical group manager.
2 IMGMA offers a variety of targeted educational opportunities.
3 IMGMA provides opportunities for members to share and dissemi-
nate information of mutual interest.
4 IMGMA maintains an active liaison with other key public and
private organizations that affect the management, funding and
delivery of quality physician care.
5 IMGMA dues are only $75 per year.
IOWA MEDICAL GROUP MANAGEMENT ASSOCIATION
iOOI Caraitdl Average, West !D@s SSoimes, BA S02SS
Please send me an application for membership!
Name Position
Organization
Address
City/State/Zip
Telephone Number Number of Physicians
Iowa Medicine
Iowa Medicine
About the Cover
Pictured on this
month’s cover is Dr.
Joseph Hall, 1 995-96
IMS president. Dr.
Hall, a Des Moines
radiologist, took office
April 30. Photo by Bob
Willitts, corporate
photographer for Iowa
Methodist Medical
Center in Des Moines.
JUNE 1995 / VOLUME 85 / 6
Editorials
Why we need to organize
Joseph Hall, MD, 1995-96 IMS president, has some valuable advice
in his inaugural column. # The President Comments
Current Issues
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: $25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
In the news
23 2
234
23 6
2 3 8
2 3 9
2 4 1
IMS Update
• IMS elects physician officers; IMS awards
• IMS domestic violence video available for loan
Futures
• Patient rights and responsibilities under managed care
• Medicare battle heats up
• Special CHMIS Update page begins this month
Legislative Affairs
• Review of bills in 1995 Iowa Legislature
• Reduction in statute of limitations does not pass Senate
Medical Economics
• Important CLIA bill introduced in Congress
• Call for medical futility guidelines
Practice Management
• Inappropriate requests for physician DEA numbers
• Part B News available through IMS
• Risk management tips from MMIC
Newsmakers
• Physicians elected to life membership
JUNE, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•THE PROCESS OF CREATING A CHMIS FOR IOWA will continue uninterrupted due to Hartford
Foundation approval of CHMIS funding for another year. The funding was crucial since the
Iowa Legislature approved a CHMIS but did not provide funding. The grant will carry the
process through the target implementation date of July 1, 1996. (Look inside this issue of
Iowa Medicine for the text of Iowa Medical Society policy on CHMIS recently approved by the
IMS House of Delegates . )
•AN IOWA MEDICAL SOCIETY VIDEO ON PARTNER BATTERING is complete and available for loan
to any IMS member physician. The 27-minute video features Iowa experts on domestic abuse
and would be ideal for a county medical society or hospital medical staff program. For
more information, call Chris McMahon at the IMS, 800/747-3070.
•lYJO IOWA HOSPITAL GROUPS plan to merge, according to a recent report in the Des Moines
Register. Allen Health Systems, which includes Allen Memorial Hospital in Waterloo, will
merge with Iowa Health System. Iowa Health System includes Iowa Methodist Medical Center,
Iowa Lutheran Hospital , both in Des Moines , and St . Luke ' s Hospital in Cedar Rapids .
•as OF PRESS TIME, THE DEADLY EBOLA VIRUS continued to spread in Zaire, chiefly affect-
ing health care workers. There have been 170 deaths. Despite the public's concern over the
virus, however, scientists and physicians are more concerned about everyday American bugs
that have learned to defy modern medicine. An alarming number of familiar bacteria have
mutated into new, highly infectious strains.
•AN EFFORT TO TURN BACK COUNTY-WIDE ANTI-SMOKING ORDINANCES in Wichita Falls, Texas was
defeated at the ballot box, due to the efforts of the Wichita County Medical Society, the
Texas Medical Association and the AMA.
•MEDICARE IS THE HOTTEST ISSUE IN WASHINGTON these days and experts say it will get
even hotter during the 1996 elections. The Medicare fund will become insolvent sometime
during the next decade, but Republican proposals for solving Medicare's budget woes are
gathering criticism from many sides. The Republicans face a self-imposed deadline of a bal-
anced budget by the year 2002, but health policy experts say cutting that much from
Medicare would almost certainly mean charging beneficiaries more while squeezing payments
to physicians and hospitals. Robert Reischauer, former director of the Congressional Budget
Office, said "the notion that this can be squeezed out of the system with greater effi-
ciencies is wishful thinking" . In an interview in the New York Times, the Republican
national chairman said the party will "go it alone" on cutting projected Medicare spending.
He believes Republicans could reap the benefits if they can take credit for saving Medicare
from bankruptcy. According to the AMA, his comments were the first indication the
Republicans are contemplating unilateral action and party-line votes to redesign Medicare.
•MEANWHILE, THE AMA IS PROPOSING a complete transformation of Medicare. Dr. Nancy
Dickey, vice chair of the AMA Board of Trustees, testified before the Senate Finance
Committee regarding Medicare's insolvency problems. AMA's proposed Medicare reform follows
five principles: 1) Encourage cost -consciousness among beneficiaries; 2) Increase price
competition among providers; 3) Reduce intergenerational inequity in financing; 4) Test
ways of reducing future generations' dependency on Medicare; 5) Reduce regulatory and
administrative complexity.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
242
S C I E N C
247
250
Advert
e Article
IMS, Iowa physicians focus on CHMIS
The Community Health Management Information System (CIIMIS)
will become law for Iowa physicians on July 1, 1996; in the interim,
many details remain undecided. This month’s feature discusses
CHMIS issues of concern to Iowa physicians. Look on pages 243-44
for the complete text of IMS policy on CHMIS adopted April 30 by
the IMS House of Delegates.
M
\ ' /
on your horizon July 1, 1996
and Education
Duodenal web with preduodenal vein
The authors describe an unusual case of an infant with duodenal
atresia and preduodenal portal vein without Down’s syndrome.
# Sergio Golombek, A ID; Jagadish Bilge MD;
Oneybuchi Ueabiala , MD
Service delivery to persons with HIV and AIDS
HIV-positive patients would benefit from pre and post-test
counseling, say these authors. # Edward Saunders, PhD; Susan
Dolphin, MSW; Berry Engebretsen, MD
253 The Editor Comments
255 The Physician Learner
Editorial Board
IMS President
Joseph Hall, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Productkm/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
ising Directory
2 56 Classified Advertising
260 Professional Listing
262 Advertising Index
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If you are a board-certified physician or a candidate for
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Iowa Medicine
Iowa Medicine
About the Cover
The 1 995 IMS award
winners are clockwise,
from left — Dr. Paul
Laube, Dubuque
surgeon , Physician
Community Service
Award; Dr. Laveme
Wintermeyer, former
state epidemiologist,
Des Moines, Merit
Award; and Dr. Herman
Hein, professor of
pediatrics, UI College of
Medicine, Iowa City,
Ben T. Whitaker Award.
JULY 1995 / VOLUME 85 / 7
Editorials
Three important issues
Thoughts on loans for medical students, the recent visit of an AMA
Trustee and a meeting with the IFMC. # The President Comments
Your help is needed!
A major fund-raising campaign will be initiated this fall for the IMS
Education Fund. # Paul Seebohm, MD
Current Issues
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine , Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
274 In the news
274 IMS Update
• IMS Directory verification letters are due
• Update on specialty representation in IMS Mouse of Delegates
276 Futures
• PPRG recommends single conversion factor
• AMA has recommendations for Medicare
• Special CIIMIS Update page outlines key issues
278 Legislative Affairs
• Statute of limitations reduction still alive for 1996
• IMS among groups discussing Patient Protection Act
279 Medical Economics
• Physicians provide “billions” in free care, says AMA
• Preventive services on endangered list?
281 Practice Management
• Implementation of new guidelines for CPT coding
• Telephone advice from MMIG
282 Newsmakers
• Awards, appointments
• Names in the news
268 Iowa Medicine Volume 85/7 July 1995
JULY, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•THE IOWA MEDICAL SOCIETY continues working with a group of large insurance companies and
others to reach a consensus on a document entitled Patient Protection Act: Principles of
Agreement under Managed Care. Besides the IMS, the group includes Deer & Company, Heritage,
Blue Cross and Blue Shield, Principal Financial and the Iowa Hospital Association. Members of
the group are now reviewing the final draft of the principles of agreement.
•AN IOWA MEDICAL SOCIETY VIDEO ON PARTNER BATTERING is complete and available for loan
to any IMS member physician. The 27-minute video features Iowa experts on domestic abuse
and would be ideal for a county medical society or hospital medical staff program. For
more information, call Chris McMahon at the IMS, 800/747-3070.
•DUE TO ITS COMPREHENSIVE EDUCATIONAL PROGRAM ON DOMESTIC VIOLENCE, the Iowa Medical
Society has been asked to participate in a national violence prevention conference to be
held in Des Moines in late October. The Conference, entitled Bridging Science and Program,
will be sponsored by the Centers for Disease Control and will be open to anyone interested
in violence issues. Watch future issues of Xowa Medicine for more details.
•CONTROVERSY OVER RULES GOVERNING PHYSICIAN ASSISTANTS continues. During the 1995 leg-
islative session, PAs introduced unsuccessful legislation to reduce the Board of Medical
Examiners authority over physicians who supervise PAs. The IMS Board of Trustees has
received a copy of a letter to Attorney General Tom Miller from the PA Board accusing the
BME of usurping the authority of the PA Board. The BME has requested an attorney general's
opinion to clarify the responsibilities of the two boards. The IMS has also submitted com-
ments to the attorney general. The IMS believes the BME is the only board with the legal
authority to regulate physicians.
•THERE WAS MUCH TALK ABOUT VARIOUS PLANS TO RESTRUCTURE Medicare at the recent AMA
meeting in Chicago. Speaker of the House Newt Gingrich spoke to AMA delegates via satellite
and outlined the Republicans' plan to "privatize" Medicare. The Speaker received several
rounds of spontaneous applause from a packed house of physicians. You'll be hearing lots
more about the AMA's Medicare proposal in coming issues of Iowa Medicine and in AMA publi-
cations .
•"TEN DIRTY DIGITS" was the title of a rather intriguing resolution introduced by the
New York Delegation at the June AMA House of Delegates. The resolution cited the fact that
the percentage of physicians who wash their hands between patients is 14-59% and called for
the AMA to "campaign for improvements in hand-washing practices".
•THE DEPARTMENT OF HUMAN SERVICES has established a work group to consider changing the
format of the Medicaid ID card and to review whether the monthly issuance of ID cards
should continue. The group would like to hear comments from physicians on how eligibility
could be verified if monthly cards were abolished. If you have comments, call Jan Walters
at 515/281-6555 or mail your comments to the Department of Human Services, Division of
Medical Services, 5th floor, Hoover State Office Building, Des Moines, 50319.
•THREE IOWA PHYSICIANS WHO SERVED as physicians in World War II are interviewed in the
August Iowa Medicine about their experiences during the Normandy Invasion and the Battle of
the Bulge. Don't miss their fascinating stories.
For more information about any deadline news item, call Chris McMahon at
JOURNAL OF THE IOWA MEDICAL SOCIETY
Feature Article
Death, dying and Iowa law
When has enough medical care been given and when should nature
be left to take its course? This article reviews Iowa law relating to
life-sustaining procedures, durable power of attorney for health
care and organ donation. # Becky Roorda, IMS manager of
PUBLIC AFFAIRS
Science and Education
Latex allergy
Over the past five years, the FDA has received over 1,100 reports of
injury and 15 deaths associated with latex allergy. 0 RK Agarwal,
MD; A Al-Shash, MD
Thyrotoxic periodic paralysis
The author discusses the pathophysiology and management of
TPP. # John DiBaise, MD
293 The Editor Comments
2 9 5 The Art of Medicine
Advertising Directory
Editorial Board
IMS President
Joseph Hall, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Prod uctitm/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
2 9 6
3 0 0
Classified Advertising
Professional Listing
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Is Not A Member Of The
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who are dedicated to consumer protection. As a member, Josephs has always adhered
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Iowa Medicine
About the Cover
Dr. George Drake, a
family practice
physician with Iowa
Physicians Clinic in
Boone , examines Debbie
Wibe of Madrid.
AUGUST 1995 / VOLUME 85 / 8
Editorials
Principles of Medicare reform
The AMA has a viable plan for restructuring a program that’s in
financial trouble. # The President Comments
Organized medicine: it’s for students, too
Once students become practicing physicians, they face many
issues which are not addressed in the medical school clinical
curriculum. % Eric Stone, M2
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
IMS staying involved in the CHMIS process
The chairman of the IMS Committee on CHMIS provides an
update on issues of concern to physicians.
# Terrence Briggs, MD
Current Issues
A In the news
314 IMS Update
• AMA condemns medical patents
314 IMS Update
• AMA condemns medical patents
315 Futures
• Medicare under a microscope
• CHMIS news for Iowa physicians
318 Legislative Affairs
• How did legislators vote on key IMS issues?
320 Medical Economics
• New rules on charges for records in Workers’ Comp cases
321 Practice Management
• First graduate of the MBS program
322 Newsmakers
• Letter to the editor, names in the news
308 Iowa Medicine Volume 85 / 8 August 1995
AUGUST, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•MEDICARE'S WOES HAVE BEEN UNDER THE MEDIA SPOTLIGHT lately and dramatic statements
made by politicians are causing consternation among the elderly, many of whom have little
understanding of the issue. Watch your mail next month for a patient information sheet pre-
pared by the Iowa Medical Society for member physicians who are getting questions from
patients about the future of Medicare. The information sheet, suitable for copying, answers
basic questions about problems in the Medicare program. The AMA is staying closely involved
in the process and has been asked several times to present testimony at committee hearings.
As of press time, the AMA was pursuing an opportunity to present its plan to the Senate
Finance Committee.
•MEDCO, THE COMPANY RETAINED BY THE STATE OF IOWA to provide managed mental health care
to Title 19 patients, is now in its sixth month of operation here. An article in the
September Iowa Medicine examines Iowa's first experience with big time managed care and
discusses concerns over some of the company's policies.
• NEW JERSEY GOVERNOR CHRISTINE TODD WHITMAN has signed into law a bill that requires
insurers and HMOs to pay for at least 48 hours of hospital care after a routine delivery
and 96 hours after a C-section. The law, which takes effect immediately, exempts health
plans that provide home health services, but only if the mother and her physician agree on
a home visit. In June, the AMA House of Delegates expressed concern over shortened OB
stays, but is also concerned over laws which dictate what should be a physician/patient
decision. Check the September Iowa Medicine for more information on the AMA/ IMS policy on
obstetrical hospital stays .
•DESPITE INTENSE EFFORTS BY THE TEXAS MEDICAL ASSOCIATION, Governor Bush has vetoed the
Texas Patient Protection Act. Governor Bush has directed the Texas insurance commissioner
to develop regulations that protect patients and physicians. The Iowa Medical Society has
been working with representatives of Heritage, Blue Cross Blue Shield and Principal on vol-
untary adoption of the principles in the AMA's Patient Protection Act. As of press time,
an agreement was close to being struck.
•UNFORTUNATELY, SMOKING AMONG YOUTH IS ON THE RISE, according to a new federally funded
study. Smoking among youth is up as much as 30% and smoking among 8th graders jumped 30%
from 1991 to 1994. Almost one in every five 13 and 14-year-olds is a sometime smoker.
•THE IOWA MEDICAL SOCIETY WILL PARTICIPATE IN A NATIONAL anti-violence conference spon-
sored by the Centers for Disease Control. (See page 314.) The conference is open to physi-
cians and registration information is now available. The conference, entitled "Bridging
Science and Program", will be held October 22-25 at the Des Moines Convention Center and
is expected to draw participants from around the country. For registration information,
call the National Conference Organizers at 404/488-4647 or fax 404/488-4349. The conference
is cosponsored by the University of Iowa Injury Prevention and Research Center and CMEs
will be available. The IMS presentation will be on domestic violence.
• THE FIRST MEETING OF THE VIOLENCE AGAINST WOMEN ADVISORY COMMITTEE was held recently,
cochaired by HHS Secretary Donna Shalala. In her opening statement, Secretary Shalala
praised the AMA's efforts in the area of violence prevention.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
324
334
'S C I E N C
331
Advert
e Article
Physicians on the front line
This year marks the 50th anniversary of the Allied victory over
Hitler. Drs. Ralph Dorner, John Hess and Robert Stickler served as
physicians during the invasion of Normandy and the Battle of the
Bulge and have a unique perspective on these historic events.
# Christine McMahon, IMS director of communications
flMfl delegates detennine medicine's agenda
The AMA House of Delegates, including members of the Iowa
delegation, approved policy on Medicare reform and other weighty
issues at the June meeting in Chicago. Check out this summary of
key actions.
A N D E D U C A T I O N
Air pellet gun injury
Air gun missile injuries in children can be associated with
significant mortality and morbidity. % Daniel Waters, DO:
Benjamin Brogilammer, MD; R. Mark Duff, MD
333 The Editor Comments
3 3 5 Physician Learner
Editorial Board
IMS President
Joseph I Iafl, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Production/Advertisiiig
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
i s i n g Directory
330 CME Seminars
336 Classified Advertising
340 Professional Listing
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
Iowa Medicine
About the Cover
Pictured on this
month’s cover is
Kenneth Schultheis,
DO, a Des Moines
emergency physician.
Photo provided by
Mercy Hospital
Medical Center.
SEPTEMBER 1995 / VOLUME 85 / 9
Editorial
The corporatization of health care
A physician’s responsibility to patients can sometimes clash head-
on with economic concerns. 0 The President Comments
Current
Issues
Iowa Medicine. Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
NATIONAL ADVERTISING:
State Medical Publishers
Network, 9534 Marshall
Drive, Shawnee Mission,
Kansas, 66215-1354, phone
913/888-8781. IOWA
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
In the news
3 5 2
3 5 4
3 5 6
3 5 8
3 6 0
3 6 2
IMS Update
• Register for national violence conference
• Specialty society update
Futures
• Managed care legislation in California
• PIIO case study report available
• Special Cl IMIS update page
Legislative Affairs
• IMS prepares for 1996 Iowa Legislature
• Pharmacist drug therapy management
Medical Economics
• Obstetrical stays — IMS, AMA policy
° Medicare fee schedule adjustment
Practice Management
• IRS crackdown on mismatched ID numbers
• More waived tests under CLIA revisions
Newsmakers
• Letter to the editor; obituaries
348 Iowa Medicine Volume 85 / 9 September 1995
SEPTEMBER, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
• DON'T MISS THE STORY ON IOWA'S NEWEST MANAGED CARE EXPERIENCE which begins on page 364
of this Iowa Medicine. This status report on managed mental health care for Title 19
patients looks at a number of interesting and difficult issues for providers.
•WATCH YOUR MAIL THIS MONTH for special Medicare educational materials being provided by
the IMS for member physicians. The IMS has created a one-page Q & A piece for patients who
don't understand basic Medicare issues. It is suitable for copying. The mailing will also
include information for physicians only regarding the AMA's Medicare proposal.
•DEAN GILLASPEY, CAE, vice president of operations and medical economics for the Iowa
Medical Society, has been elected to a two-year term on the board of directors of the
American Association of Medical Society Executives (AAMSE) . He was installed at the AAMSE
annual meeting in August .
•AN INFLUENTIAL GROUP OF 22 MINNESOTA EMPLOYERS has decided that bigger isn't better
when it comes to health plans. The employers will now negotiate directly with smaller,
organized groups of doctors and hospitals and give employees information on cost, quality
and consumer-service performance. The employees will receive monthly vouchers toward premi-
ums and will shop among the competing groups. A spokesman for the employers said their
goal was to "get employers and health plans out of the middle" of transactions between
doctors and patients.
•BLUE CROSS AND BLUE SHIELD CEO ROBERT RAY announced his retirement late last month and
the search has begun for his replacement. Top candidates now being mentioned include Blues
senior officers Duane Heintz (senior vice president, provider network) ; Craig Hennessy
(chief operating officer) ; Robert Millen (chief development officer) ; and Richard Stilley
(chief administrative officer). Robert Ray will step down at the end of 1996.
•THE PRESIDENT, THE AMA AND OTHER CONCERNED GROUPS held a joint press conference
recently to call for federal regulation of tobacco. At least 100 organizations have sent
petitions to the White House; 40 conservative Republican doctors sent a letter to House
Speaker Newt Gingrich urging that the issue be considered as a health concern, not a
political one. Meanwhile, House Minority Leader Richard Gephardt has joined forces with
tobacco-state Democrats to block any White House plans to extend federal regulations to
cigarettes .
• THE AMA HAS BEEN A VISIBLE PRESENCE ON THE HILL recently, touting the merits of the
AMA Medicare transformation proposal and presenting testimony on important issues ranging
from domestic violence to tobacco. AMA Board of Trustees member Tim Flaherty, MD, appeared
before the Senate Labor Committee as it received testimony on a bill which would outlaw
the emerging insurance industry practice of terminating the coverage of victims of domestic
violence .
• THE IOWA MEDICAL SOCIE7TY IS PARTICIPATING in a group which is studying 24-hour post-
partum discharge. The group, which is working through the Des Moines Infant Mortality
Prevention Center, will conduct a survey of mothers four to eight weeks following discharge
from the hospital. The survey will begin in early 1996.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
Feature
Article
Managed care comes to Iowa
The state of Iowa and Iowa psychiatrists are six months into Iowa’s
first major experience with managed care. This article discusses
Title 19 managed mental health care as it is being administered by
Medco Behavioral Care. Physicians and others have concerns
about the effect the program might have on patients.
# Christine McMahon, IMS director of communications
Science and Education
Metastasis of adenocarcinoma of breast to
gluteus medius
The authors describe an unusual case of rapid progression of
infiltrating ductal carcinoma to multiple sites.
# Subhash Sahai, MD; Darcy Leigh, DO
373 The Editor Comments
255 The Art of Medicine
Advertising
Directory
Editorial Board
IMS President
Joseph Hall, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Production/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
376 Classified Advertising
380 Professional Listing
382 Advertising Index
We’ve Pinned Our Hopes on You
With historic change in Des Moines and Washington, IMPAC and AMPAC need your help so that your voice is heard in the
state legislature and the new Congress.
To make sure Congress listens to our concerns, we must be united. That’s why we’re pinning our hopes on you to join IMPAC/
AMPAC today. Your membership will add strength to our efforts to protect our patients and improve America’s health care
system. By joining IMPAC/AMPAC today, you will help show the new Congress that physicians must be a vital part of any
legislation that affects our profession.
AMPAC has redesigned its 1995 Sustaining Membership Pin. We hope you will wear it proudly in your grassroots efforts to
help promote physician involvement at all levels. We’re pinning our hopes on you.
Join IMPAC Today
Name:
Home Address:
ij-o
Business Address:
ME Number (if known):
Have you been an AMPAC member before? □ No □ Yes
would like to be a: □ Sustaining Member ($100)
□ Gold Club Member ($250)
Please send your membership contribution to:
Iowa Medical Political Action Committee
1001 West Grand Avenue
West Des Moines, Iowa 50265
Voluntary political contributions by individuals to state PA C/A MPAC should be written on personal checks. Funds from corporations will be used for political education activities and/or state-election activities where allowed.
Contributions arc not limited to the suggested amounts. Neither AMA nor its constituent state associations will favor or disadvantage anyone based upon the amounts of or failure to make PAC contributions. Voluntary political
contributions are subject to limitations of FEC regulations Section 110.1, 110.2 and 110.5 (Federal regulations require this notice).
Contributions to slatcPAC/AMPAC are not deductible as charitable contributions for federal income tax purposes.
O'
Iowa Medicine
About the Cover
Shawn Sabin, MD, a
dermatologist prac-
ticing in Dubuque,
examines Wayne
Jewett, also of
Dubuque. Photo
provided by Karen
Knepper of Finley
Hospital.
OCTOBER 1995 / VOLUME 85 / 10
Editorial
Why I belong
IMS president Joseph Hall, MD discusses some of the incentives for
membership in the Iowa Medical Society and involvement in
organized medicine. # The President Comments
Current Issues
392 In the news
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: 825 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
3 9 2
3 9 4
3 9 6
3 98
4 0 0
IMS Update
• Patient grievances increase
• Infant mortality continues to decline in Iowa
Futures
• Managed care will dominate Iowa in five years, says expert
• Managed substance abuse care begins here
• CI1MIS Governing Board rules on release of data
Legislative Affairs
• IMS committee sets 1996 legislative priorities
Medical Economics
• Final rule on Stark I self-referral law
• Lawyers face increased number of malpractice suits
Practice Management
• HGFA will reject truncated ICD-9 codes
• Confidentiality is the basis for patient trust
402 Newsmakers
• Letters to the editor, new members, awards, appointments
388 Iowa Medicine Volume 85/ 10 October 1995
OCTOBER, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
• IOWA MEDICINE'S SEPTEMBER STORY ON MEDCO was quoted in a front page September 18 story
by Des Moines Register reporter Bill Leonard. The story, entitled "Managing mental health:
Sacrificing the poor to save a few bucks?", explored complaints about the managed care com-
pany in charge of providing mental health care to Iowa's Medicaid patients. IMS leadership
and staff are continuing to meet with representatives of Medco, the Iowa Department of
Human Services and the Governor's office to try and work out problems. We'll keep you post-
ed. Any physician who missed the Register story can get a copy by calling Chris McMahon at
the IMS, 800/747-3070 or 515/223-1401.
• IN THE NOVEMBER ION. A MEDICINE, Congressman Greg Ganske discusses the goings-on in our
nation's capitol, specifically in the area of Medicare reform. Congressman Ganske will dis-
cuss the Republican plan for reforming Medicare and feedback he received at recent town
meetings held across Iowa. The Republican plan reportedly calls for an annual $50 increase
in deductibles for doctor services as well as 20% of charges for lab tests, home health and
some skilled nursing facility services.
•A CONTINGENT OF IMS LEADERS went to Washington, DC this week to meet with Iowa's con-
gressional delegation and to attend an AMA grass roots political education conference. IMS
leaders planned to meet with congressmen to discuss Medicare and Medicaid reform.
• THE ISSUE OF HOW MUCH INFORMATION SHOULD BE MADE PUBLIC when a physician is charged by
the Board of Medical Examiners has hit the news lately. The IMS has filed a petition of
intervention in the John Doe II case. The IMS position is that the statement of charges (a
public document) should contain only the physician's name, the date of the occurrence and
the statute the physician is alleged to have violated. IMS leaders plan to meet soon with
representatives of the BME to discuss issues of mutual concern.
• DON'T FORGET THAT THE GREAT AMERICAN SMOKEOUT is November 16. What's the best advice for
your patients about quitting? Richard Corlin, MD, a member of the AMA Board of Trustees, tells
patients to switch brands with every pack they buy. "I tell them to buy a brand they've never
smoked and to smoke the entire pack, even if they don't like the taste." The theory is that
some people continue smoking because they like the taste of a particular brand.
•A MAJOR TRANSFORMATION OF THE AMA's CPT CLEARINGHOUSE is underway. Since it opened in
1991, it has served as an excellent resource for physicians seeking interpretation of CPT
codes. The Clearinghouse is undergoing reorganization because the number and complexity of
inquiries was beginning to be overwhelming. During the reorganization, the Clearinghouse
cannot respond to telephone or written requests. The Clearinghouse will reopen in late
October for AMA members.
• THERE WILL BE A SPECIAL FEATURE ON MEDICARE CODING by Iowa physicians in the November
Iowa Medicine. E & M coding documentation guidelines from the Health Care Financing
Administration have been released; don't miss this first look at how Iowa physicians appear
to be complying with the guidelines.
•A NUMBER OF GOVERNMENT MATERIALS can now be found on Internet's World Wide Web. These
include the Federal Register, the Congressional Record, the US Code and other information.
The Web address is: http://ssdc.ucsd.edu/gpo.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
404
S C I E N C
409
Advert
Article
Bound by common interests
A vigorous physician-owned delivery system can retain market
share which hospitals by themselves could lose to larger centers.
# Cooper Parker, Physician Network Management, Inc.
and Education
Alzheimer's disease: the role of tacrine therapy
The author discusses criteria for tacrine therapy, the only agent
approved for treatment of Alzheimer’s Disease.
# Gerald Jogerst, MD
4 0 8 Upcoming CME Seminars
4 13 The Editor Comments
415 Physician Learner
ising Directory
4 16 Classified Advertising
4 2 0 Professional Listing
4 2 2 Advertising Index
Editorial Board
IMS President
Joseph IJall,MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Production/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
It’s
A Mazing
The Decisions
Involved In Running
A Medical Practice
You're a physician and you know the complexities
of running your own practice. There are many
services you and your staff need to operate more
efficiently. Weaving your way through all of the
programs and products, however, can be
overwhelming.
Sure, you could have a piecemeal approach to your
needs. But why, when you could have one-stop
• Professional Liability Insurance
• Financial Planning
• Overnight Air Express Service
• Health Insurance
• Workers Compensation Insurance
• Disability Insurance
• Subscription Services
• Life Insurance
• Rental Car Discount
shopping with IMS Services. With many of the
services available in one location, it can make your
practice operate smoother and keep you on the
road to running a successful practice.
So contact IMS Services to be unmazed with all the
programs and products available. For further
information on any of the following, please call
515/223-2816 or 800/728-5398.
• Specialty Society Management Services
• Practice Management Consulting
• Medical Office Seminars
• Retirement Planning
• Credit Programs
• Long Distance Telephone Service
• Debt Collection
• Electronic Medical Records Endorsement
• Individual Travel Club
SERVICES
A SUBSIDIARY OF THE IOWA MEDICAL SOCIETY
1001 Grand Avenue, West Des Moines, Iowa 50265
Iowa Medicine
About the Cover
Jeff Boycl, MD
examines a patient.
Dr. Boyd is an Iowa
Heart Center
cardiologist who
practices at the Ames
McFarland Clinic.
NOVEMBER 1995 / VOLUME 85 / 11
Editorials
PflCs are a reality
In an ideal society, PACs would not be needed. Unfortunately, we
don’t live in an ideal society. # The President Comments
The right to privacy vs. the public’s right to know
A legal battle involving Iowa physicians and the Iowa State Board of
Medical Examiners has been much in the news lately. The IMS
president discusses the Society’s position. # Joseph H.kll , MD
Current Issues
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: $25 per
year Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
AA.A In the news
434 IMS Update
• Schedule change for Iowa Medicine
436 Futures
• IMS, IPS continue meeting with Medco
• IMS will not bid on Cl IMIS repository
438 Legislative Affairs
• More on PA rules, drug therapy management by pharmacists
440 Medical Economics
• MBC pays previously denied claims
441 Practice Management
• IMS data collection project
Newsmakers
• Letter to the editor, awards, appointments
428 Iowa Medicine Volume 85/11 November 1 995
NOVEMBER, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
•ARE YOU AT RISK? Don't miss the feature on Stark II provisions in the December Iowa
Medicine. Three attorneys discuss what Stark II means to physicians' practices now and what
it will mean in the future.
•AS OF PRESS TIME (10/25), a majority of Iowa's congressional delegation had voted in
favor of the Republican plan to reform Medicare. Iowa Congressmen came on board after
Speaker Gingrich made concessions on the urban-rural differential in payment for Medicare
managed care plans. Gingrich agreed to raise the floor to a minimum $300 per-month charge.
The AMA is supporting the GOP plan, saying it will empower patients to make their own
choices and that it recognizes the extraordinary value of physicians in managing and deliv-
ering health care. The plan will also "remove red tape and liability barriers that disturb
the patient -physician relationship", says the AMA. Physicians are cautioned not to take as
gospel all the media reports on the Medicare debate. Some are erroneous or tell only part
of the story.
•SCAM ARTISTS ARE MOVING INTO THE MANAGED CARE ARENA and IMS has heard recently of sev-
eral Iowa physicians receiving solicitations for questionable managed care enterprises.
Physicians are cautioned to send no money until you check a company's credentials.
•IMS HAS RECEIVED NOTIFICATION that Blue Cross and Blue Shield will raise the base
rate for its Statewide Physicians Group Health Plan by 13.8% in 1996. Rates could be fur-
ther adjusted (up or down) depending on demographics. The IMS Committee on Member Services
plans to meet with Blues officials this month to discuss the factors behind the rate hike.
•THIRTY PERCENT OF BABIES IN THE U.S. are born out of wedlock, up from 18% in 1980,
according to a recent Kiplinger Newsletter. Experts believe the number of babies born to
unwed mothers will continue to rise, a trend which has far-reaching implications for
America's schools, health care system and employers.
•THERE HAS BEEN A SLEW OF CONGRESSIONAL RESIGNATIONS AND RETIREMENTS led by GOP Sen.
Packwood and Democratic Rep. Reynolds, both stepping down due to scandals. Democratic Rep.
Mineta of California will become a Lockheed exec. Eight senators (one Republican and seven
Democrats) and 12 House members (four Republicans and eight Democrats) also plan to leave
at the end of 1996. Political analysts theorize this will further reduce Democratic changes
of taking control of Congress after next year's elections.
•THE IOWA MEDICAL SOCIETY Board of Trustees met last week with members of the CHMIS
Executive Committee to get an update on the progress of CHMIS implementation. The CHMIS is
scheduled to be operational in Iowa July 1, 1996. CHMIS committee members addressed a num-
ber of questions and concerns. Board members were particularly interested in the issues of
how much of the cost of CHMIS will be borne by physicians, verification of insurance eli-
gibility and the ethical implications of collecting sensitive and/or confidential informa-
tion from patient records and placing it in a data repository. At its October meeting, the
IMS Board also decided the IMS will be unable to meet requirements to become the CHMIS
data repository and will not bid on the project. This information was shared with the IMS
Committee on CHMIS at that group's October meeting.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
Feature
Articles
E & M documentation — is Iowa complying?
Practical advice from the co-chairs of the Medicare Carrier
Advisory Committee on Iowa compliance with HCFA documen-
tation guidelines. # John Olds, MD; Kext Moss, MD
Greg Ganske on Medicare reform
The text of a statement read by Rep. Ganske October 2 when the
Medicare Preservation Act was introduced in the House Commerce
Committee. # Congressman Greg Ganske
Science and
Education
flpnea and vomiting due to cocaine exposure
Case report of an infant with apnea and vomiting as a result of
passive exposure to cocaine. # Enehomere Okoruwa, MD;
Rizwan Shah, MD; Karen Gerdes, MD
4 4 8 C M E Seminars
453 The Editor Comments
455 The Art of Medicine
Advertising
Directory
Editorial Board
IMS President
Joseph Hall, MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Producticm/Advertisntg
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
456 Classified Advertising
4 5 8 Advertising Index
460 Professional Listing
Iowa Medicine Volume 85/11
November 1995
429
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
Iowa Medicine
Iowa Medicine
About the Cover
Dr. Onyebuchi Ukabiala
examines a premature
baby. Photo provided
courtesy of Mercy
Hospital Medical
Center, Des Moines.
ECEMBER 1995 / VOLUME 85 / 12
Editorials
AMA’s role in the Medicare reforni bill
At a recent meeting of the North Central Medical Conference, AMA
President Lonnie Bristow, MD discussed the AMA’s efforts to
improve the Medicare conversion factors.
# The President Comments
Farewell to a friend
After 43 years with the Iowa Medical Society staff, Tina Preftakes is
retiring December 31. # A SPECIAL tribute
Iowa Medicine, Journal of
the Iowa Medical Society
(ISSN 0746-8709), is
published monthly by the
Iowa Medical Society.
Subscription price: S25 per
year. Second class postage
paid at Des Moines, Iowa
and at additional mailing
offices. POSTMASTER:
Send address changes to
Iowa Medicine, Journal of
the Iowa Medical Society,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
ADVERTISING: Jane
Nieland, Iowa Medicine,
1001 Grand Avenue, West
Des Moines, Iowa 50265.
Phone 515/223-1401.
EDITORIAL CONTENT:
The Society is unable to
assume responsibility for
the accuracy of that which
is submitted. Manuscripts
or editorial inquiries should
be directed to the Editor,
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Copyright 1995 Iowa
Medical Society.
Current Issues
A *7 A In the news
474 IMS Update
• IMS offices up for election
475 Futures
• AMA president meets with senior citizens
• Important advice on CIIMIS networks
477 Legislative Affairs
• Legislature convenes January 8
Medical Economics
• GLIA reform; what to do if you’re sued
481 Practice Management
• Results of IMS practice management survey
483 Newsmakers
• Awards, appointments, names in the news
468 Iowa Medicine Volume 85 / 12 December 1995
DECEMBER, 1995
IMS DEADLINE news
Late-breaking news of interest to Iowa physicians
• MANAGED CARE WILL BE THE FOCUS OF A BRAND NEW SECTION in Iowa Medicine which debuts
in January. The two-page section will be entitled "Managed Care — News You Can Use". The
new section will highlight topics such as practice parameters, managed care liability and
the ethics of managed care. The section will also contain information about resources
available from the IMS for its member physicians.
•CONGRATULATIONS TO DR. ROGER CEILLEY who was recently elected president-elect of the
American Academy of Dermatology for 1996. Dr. Ceilley practices in West Des Moines.
•IOWA'S MEDICARE CARRIER HAS MAILED 1996 FEE SCHEDULES and the "Dear Doctor" letter.
Physicians who wish to change their participation status must return the Dear Doctor letter
postmarked by December 31. (Keep a copy and send the letter certified mail to document the
postmark.) The fee schedules as mailed were based on three separate conversion factors. If
Congress and the President can agree, it appears we may move to a single conversion factor
as part of Medicare reform and the fee schedules for 1996 would have to be recalculated.
If you have questions, call Barb Cannon Heck of the IMS staff.
•THE DEPARTMENT OF HUMAN SERVICES has decided to scuttle a plan to bundle diagnostic
lab and ultrasound charges into Medicaid's obstetrical global billing (Physicians
Informational Release no. 95-5) without an increase in the global fee. When the plan was
announced, IMS staff estimated the services being bundled could total $500. IMS approached
the DHS to voice extreme concern on behalf of Iowa physicians and the DHS reevaluated the
decision. Physicians will receive a letter of explanation from Unisys — the Medicaid fiscal
intermediary — completely rescinding the policy. If you have questions, call Barb Cannon
Heck of the IMS staff.
•THE IMS DOMESTIC VIOLENCE VIDEO has won honorable mention in the Golden Circle Awards
sponsored by the American Society of Association Executives. "Break the Silence; Begin the
Cure" was produced by the IMS Task Force on Domestic Violence and competed against over 40
videos submitted by associations from all over the country.
• LOOK ON PAGE 476 OF THIS IOWA MEDICINE for important advice about choosing a CHMIS
network so you will be prepared for the July 1, 1996 start of CHMIS implementation. There
will be no certified networks as of July 1, and it is imperative that you understand what
this means for your practice before vendors begin their marketing efforts.
• POLITICAL SURVIVAL SKILLS will be the focus of a workshop planned for Wednesday,
January 17 at IMS headquarters. Keynote speaker will be Michael Dunn, a political consul-
tant based in Washington, DC. The workshop fee is $25. To register, call Sandy Nichols at
the IMS, 800/747-3070.
•THE BLUES HAVE matt .ren PHYSICIAN PROFILES to Blue Advantage Network physicians. Using
1994 Blue Shield claims data, the report compares practice patterns of individual physi-
cians to other network physicians and specialties. A survey was mailed with the report.
Physicians are encouraged to carefully review the report and return the survey so the Blues
will receive feedback on the validity of the physician profiles. Contact Ed Whitver of the
IMS staff if you have questions on IMS activities in the data/technology area.
For more information about any deadline news item, call Chris McMahon at
IMS headquarters, 515/223-1401 or 800/747-3070.
JOURNAL OF THE IOWA MEDICAL SOCIETY
F E A T U R
484
S C I E N C
489
Advert
e Article
Stark self-referral law
In September, after nearly a four-year delay, regulations for Stark I
took effect. Should Iowa physicians be concerned about the effect of
Stark on their practices? These authors say they should.
# Steves Beck, JD; David Glaser. JD
e and Education
Prostate cancer management in older patients
Use of radical prostatectomy as definitive therapy has increased
dramatically in the past decade. However, there is a controversy
regarding the optimal management of this malignancy in older
patients. # William See, MD
491 Tiie Editor Comments
493 Physician Learner
4 9 4 Index to Volume lxxxv
ising Directory
4 9 6 Classified Advertising
500 Professional Listing
Iowa Medicine Volume 85/1
Editorial Board
MS President
Joseph I Iall.MD
Scientific Editor
Marion Alberts, MD
Executive Editor
Eldon Huston
Managing Editor
Christine McMahon
Production/Advertising
Manager
Jane Nieland
All articles published in
Iowa Medicine are listed
in Index Medicus
2 December 1995 469
It’s
A Mazing
The Decisions
Involved In Running
A Medical Practice
Y’ou’re a physician and you know the complexities
of running your own practice. There are many
services you and your staff need to operate more
efficiently. Weaving your way through all of the
programs and products, however, can be
overwhelming.
Sure, you could have a piecemeal approach to your
needs. But why, when you could have one-stop
• Professional Liability Insurance
• Financial Planning
• Overnight Air Express Service
• Health Insurance
• Workers Compensation Insurance
• Disability Insurance
* Subscription Services
• Life Insurance
* Rental Car Discount
shopping with IMS Services. With many of the
services available in one location, it can make your
practice operate smoother and keep you on the
road to running a successful practice.
So contact IMS Services to be unmazed with all the
programs and products available. For further
information on any of the following, please call
515/223-2816 or 800/728-5398.
• Specialty Society Management Services
• Practice Management Consulting
• Medical Office Seminars
• Retirement Planning
• Credit Programs
• Long Distance Telephone Service
• Debt Collection
• Electronic Medical Records Endorsement
• Individual Travel Club
services
A SUBSIDIARY OF THE IOWA MEDICAL SOCIETY
1001 Grand Avenue, West Des Moines, Iowa 50265
IovvalMedicine
THE PRESIDENT COMMENTS
Watch for red flags
I conducted an informal survey in the doc-
; tors’ lounge and found a number of phvsi-
■ cians with a story on domestic violence. It’s
not every day that physicians see domestic
violence, hut it occurs frequently enough that
each physician could recall a case. One physi-
cian admitted he should consider domestic
violence more frequently and that may be true
for many of us.
A general surgeon recalled a woman whose
life was saved by surgical intervention after she
was stabbed. To the chagrin of the surgeon, the
patient returned to the live-in friend who knifed
her. The case points out the physician’s frus-
tration and why more understanding and knowl-
edge on dealing with these cases is necessary.
Another physician, an internist, tells of a
middle-aged woman he saw many
times for minor injuries. She at-
tributed the minor fractures and
bruises to accidents which oc-
curred while caring for her grand-
children. “I just can’t keep up with
them any longer,” she would say.
Finally, he received a phone call
from her and she was staying at
the battered women’s shelter. For the first
time, the true story came out. She had been
abused by her husband for years. This case
indicates the need to routinely screen for abuse,
be alert for red flags and ask the right questions.
When you see a suspicious injury, interview
the patient alone and ask a direct question.
Remember, an abusive partner may come with
the patient and insist on staying close. An
overly solicitous partner — eager to explain the
injury and answer the questions — is suspect.
The following are examples of questions that
should be asked: Do you feel safe in your
home? Are you in a relationship in which you
feel you are badly treated? Flas your partner
ever prevented you from leaving the house,
seeing friends, getting a job or continuing your
education? Do you feel you have to walk on
eggshells around your partner?
Even in my otolaryngology practice, I had an
experience with child abuse. A family physi-
cian from out of town referred a preschooler on
a Friday evening, supposedly for ear lacera-
tions that needed suturing. When the little girl
was seen in the emergency room she had tears
behind the ears extending into the fascia. Close
inspection indicated fingernail
marks in front of the ears. The
mother said her son had just picked
the patient up from preschool. I
showed the mother how the ears
were probably pulled, causing the
injury. The mother confronted the
teacher, who confessed that she
disciplined the little girl. The child
was removed from the preschool.
Physicians are in a distinct position to iden-
tify battered women and other victims of do-
mestic violence. However, we can’t do it alone.
We should check to see if our hospital emer-
gency departments have a way to identify and
support the battered patients and become fa-
miliar with community support groups. E3
It occurs
frequently
enough that
each physician
could recall
a case.
James White, MD
Medical Protective Policyowners
NEVER get letters like this!
Any allegation of malpractice against a doctor is serious business. If you are insured by The Medical
Protective Company, be confident that in any malpractice claim you are an active partner in
analyzing and preparing your case. We seek your advice and counsel in the beginning, in the
middle, and at the end of your case. In fact, unless restricted by state law, every individual Medical
Protective professional liability policy guarantees the doctor's right to consent to any settlement-
no strings attached! In an era of frivolous suits, changing government attitudes about the
confidentiality of the National Practitioner's Data Bank and increased scrutiny by credentialing
committees, shouldn't you have The Medical Protective Company as your professional liability
insurer? Call your local General Agent for more information about how you can have more control
in defense of your professional reputation.
A+ (Superior) A. M. Best
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Iowa [Medicine
GUEST EDITORIAL
Give the gift of hope
I congratulate you and your Iowa colleagues
in organized medicine for your efforts to
educate all Iowa physicians regarding do-
mestic violence. Because a physician may be
the first non family member to whom an abused
woman turns, physicians have a unique ethical
responsibility to intervene.
As we enter a new year, we can make a
special effort to help those who are striving to
escape the bonds of family violence. While our
campaign to educate physicians and the public
about domestic violence is successful, it also
increases the demand on the shelters that care
for battered women and children.
But donations to these islands of safety have
not increased to meet the new demand. In light
of the rising awareness, you may ask: Why
aren’t more people giving? Ac-
cording to Ann Kaplan, editor of
Giving USA , “It’s easier to give to
a specific, well publicized event
than to a diffused need like pov-
erty or (to survivors of family)
violence.”
What can individual physicians
and medical societies do to help?
We can help support our patients’ decision to
become survivors in 1995. We can give the gift
of hope.
Here are some suggestions:
•Make 1995 a truly new year for a victim of
domestic violence by giving financial support
for counseling and advocacy services to your
local shelter or community outreach service.
•Give gift certificates from supermarkets and
discount stores to shelters and community
outreach services. This helps them provide
sheltered women and children with fresh milk,
dairy products, produce, meat, shoes and needed
household items all during the year.
•Donate gift items like new clothing for wo-
men and children to the shelters; also un-
wrapped non-violent toys, books and games.
Most shelters will display these items so moth-
ers can chose suitable ones for themselves and
their children.
•Adopt a shelter. Shelters need bed linens,
blankets, towels and washcloths all during the
year. They will accept used items that are clean
and in good condition. Linens for baby cribs,
single and bunk beds top their list.
•Gall your local battered women’s shelter
and ask what you can do to help.
The IMS staff has a complete list of
shelters in Iowa.
Since the IMS Board of Trust-
ees has identified domestic vio-
lence as a priority issue, in De-
cember the IMS staff chose the
local domestic violence shelter for
a holiday giving project. Staff
members donated clothing, toys and other per-
sonal items sorely needed at the shelter.
I thank you, your medical society and physi-
cian members for your strong support in the
campaign to end family violence. Thank you,
too, for joining me in taking another step down
this long road. Physicians can do much to
assure shelters and family services are there to
help us protect our patients from abuse. O
We can
help support
our patients’
decision to
become
survivors.
Robert McAfee, MD
AMA president
Dr. McAfee, a surgeon prac-
ticing in Maine, has identi-
fied domestic violence as
his issue of focus during
his presidential term.
“Onpriizing lor Change” cassette tapes available
uBe creative, but go into any arrangements with your eyes open, recognizing
there are not going to be any absolute winners.” Ken Davis, JD
“You have to be able to negotiate with the big gorillas in the marketplace.” Bill DeMarco
“Hospitals have been a driving force in rural Iowa because of the small num-
ber of physicians.” Ed McIntosh, JD
“As managed care makes further inroads in Iowa, having a good information
system will be critical to the success of any PO.” TomGorey, JD
“When the American public sees what is happening to their freedom of choice, there
will be a public backlash against managed care.” James Todd, md, executive vice president, AMA
Here’s what Iowa physicians said about the expert presentations at “Organizing for Change”
“ The speakers were well-focused arid authoritative. A high quality meeting. "
“/ wish all Iowa physicians could hear this program. ”
“ Excellent hands-on information. ”
“ Very high quality program. Keep them coming. ”
“ Plenty of useful, practical advice. Almost too much to take in. "
“T/ie speakers' level of knowledge and insight was impressive. ”
If you missed the “Organizing for Change" conference, you can order a set of cassette tapes containing the entire
day’s program, including Dr. James Todd’s entertaining luncheon presentation. The cost of the tapes and related mate-
rials is $42.00. The set of cassettes without related materials is $26.25. To order, use the order form below or call
Barbara Heck or Linda Tideback at the IMS, 515/223-1401 or 800/747-3070.
Cassette tape order blank, “Organizing for Change” speakers
I Please send me:
j Cassette tapes on “Organizing for Change” for $26.25
Cassette tapes on “Organizing for Change” plus related written materials for $42.00
| NAME
ADDRESS
| CITY, STATE, ZIP
Price includes shipping, handling and taxes. Prepayment is required. Please make check payable to the Iowa
Medical Society. Mail check and order blank to: Iowa Medical Society, 1001 Grand, West Des Moines, IA
j 50265. Attn: Linda Tideback.
These materials are the property of the authors. They are published by the Iowa Medical Society for the exclusive use of the purchaser. Distribution of these
i printed materials or the accompanying audiotapes or the duplication of the materials or tapes without the express written permission of the Iowa Medical
Society is strictly prohibited and is a violation of U.S. and international law.
i i
Iowa [Medicine
GUEST ARTICLE
A mass media
reality check
t is well-documented that repeated expo-
sure to a particular behavior can cause a
I person to emulate that behavior. Repeated
exposure to violence in the mass media, par-
i ticularly at young ages, can have lifelong conse-
quences. Nearly four decades of research by
t the APA Commission on television viewing and
other media are conclusive: Higher levels of
viewing violence in the mass media are corre-
lated with increased aggression in children and
increased acceptance of aggressive attitudes by
children.
Depictions of sexual violence, primarily in
R-rated films and messages about violence
against women appear to influence attitudes of
adolescents about rape and violence toward
women. These attitudes carry over into adult
life. Such behavior is often acted
out as spouse abuse or other seri-
ous criminal behavior.
While politicians and TV ex-
ecutives argue over whether or not
TV violence should be reduced,
over 200 studies tell us there is
reason to be concerned. Research
shows that by the time the average
child turns 18 years of age, he or she will have
spent 11,000 hours in school and more than
15,000 hours watching television. To put this
TV time in perspective, a person could graduate
from both medical and law schools utilizing the
same number of hours studying. Instead, a
child may see 22,000 acts of television violence
by age 13 and 80,000 by age 18.
Statistics also show that in the past 30 years,
violence has replaced disease as the number
one killer of children. Teenagers are approxi-
mately two and one half times more likely to be
victims of violent crime than they were 20
years ago. The homicide rate among teens from
1984 to 1993 increased 121% for 17 year olds,
217% for 15 year olds and 100% for children
under 12, according to the National Crime
Analysis Project at Northeastern University.
If violence on TV is a major contributor to
the violence on our streets and in our homes,
physicians should look on TV with the same
concern they have for a contagious disease.
The IMS Alliance offers you the opportunity
for a “reality check” by viewing the AMAA
video, “Violence in America.” This video is a
powerful three-minute presentation featuring
actual clips from movies, televi-
sion shows, media reports and
children’s cartoons that graphi-
cally depict why violence in
America has reached epidemic
proportions. It is narrated by Tom
Browkaw with the plaintive strains
of a woman singing chilling words
in the background: “Didn’t any-
body tell them that’s not how it has to be?” The
video is available for purchase or for a two-week
“free” rental through the IMSA.
The Alliance is committed to our goal of
“Zero Tolerance for Violence”; violence in the
media is just one of our many targets. We are
pleased to make this video available to you. m
Violence
has replaced
disease as
the number
one killer
of children.
Barbara Bell
President
IMS Alliance
Begin the Cure
Iowa [Medicine
IMS Update
AT A GLANCE
Robert Kelch, MD, the
new clean of the Univer-
sity of Iowa College of
Medicine, will be the
guest luncheon speaker
at the Thursday, Janu-
ary 12 meeting of the
IMS Executive Council.
Edward Howell, direc-
tor of the UI Hospitals
and Clinics, will cdso
give a presentation.
♦
A second IMS dues meal-
ing was be sent in mid-
December. If you haven 't
yet paid your IMS dues,
your prompt attention
to this matter will be
appreciated.
•
Updated copies of the
IMS Articles of Incor-
poration and Bylaws are
available by calling
Sandy Nelson at IMS
headquarters, 515/223-
1401 or 800/747-3070.
IMS Annual Meeting April 28-30
The 1995 IMS House of Delegates and
Scientific Session will be Friday-Sunday,
April 28-30 at the Marriott Hotel in Des
Moines. Make your room reservations by call-
ing the Marriott at 800/228-9290.
The House of Delegates meets Saturday at
8:30 .am. and Sunday at 10 a.m. County soci-
eties should be identifying their delegates to
the 1995 Douse. Each county is entitled to at
least one delegate and one alternate, with one
additional delegate and alternate per 15
active, resident or life members.
Any member can submit a resolution for
consideration by the 1994 House. Reso-
lutions must be sponsored by a county soci-
ety, a delegate or a Councilor District and
may address any issue concerning medical
care or practice.
1995 IMS offices to be filled by the House
include (length of term in parenthesis): pres-
ident-elect (1); vice-president (1); trustee (3);
House speaker and vice speaker ( 1 ); AMA del-
egate (2) and AMA alternate (2). Judicial
Councilors in Districts 1, 6, 9 and 13 (all two-
year terms) are also up for election.
Below is the District caucus schedule. If no
information was available from your district
at press time, call Barb Walker at the IMS,
800/747-3070.
Nominees wanted for physician award
IMS is seeking nominees for its Physician
Award for Community Service. The award
will be presented during the 1995 House of
Delegates. The award honors an Iowa physi-
cian who has provided outstanding civic,
charitable and health services. Service should
be uncompensated. The deadline is March 1.
Anyone can nominate a physician by writ-
ing to Tina Preftakes at the IMS, 1001 Grand,
West Des Moines, IA 50265.
Give the physician’s name and address, a
picture of the physician and a description of
why he or she should be considered. The
recipient will be chosen by the IMS Trustees.
Clinic manager award nominees sought
Nominees are being sought for the 1995
Outstanding Iowa Medical Office Adminis-
trator Award.
A panel of member physicians will select
the winner and the award will be presented at
the IMS House of Delegates April 28-30 at the
Marriott Hotel in Des Moines.
To nominate a clinic manager for this award,
call Dana Petrowsky at IMS Services, 515/223-
2816 or 800/728-5398 by February 15. DU
Iowa
Medical Society 1995 District Caucuses
Dist.
Date
Location and Time
Councilor
1
1/25
Pzazz in Burlington, 6:30 pm
Robert Kent, MD
2
2/1
Highlander, Iowa City, after business meeting
William Bonney, MD
3
2/9
River City Cafe, Davenport, 7 pm
Eugene Kerns, MD
4
1/10
Mercy Cafeteria, Cedar Rapids, after 7 pm meeting
Albert Coates, MD
5
1/24
Knight-Light Supper Club, Dyersville, 6:30 pm
Ross Madden, MD
6
2/14
Prime N Wine in Mason City, 6:30 pm
John Justin, MD
7
2/7
Star Lite Hotel in Waterloo, after business meeting
Steven Erickson, MD
8
1/12
Steak Center in State Center at 6 pm
Leo Milleman, MD
9
1/3
Ottumwa Country Club in Ottumwa at 6 pm
Jay Heitsman, MD
10&11
1/24
Glen Oaks in West Des Moines at 6 pm
Michael Disbro, MD
C. David Smith, MD
12
Contact IMS for site information
John Fernandez, MD
13
1/9
Stewart Memorial Comm Hosp, Lake City at 7:30 pm
Linda Her, MD
14
1/26
The Hotel in Spencer at 7 pm
Stephen Richards, DO
15
2/16
Sioux City Country Club, 6 pm social hour, 7 pm dinner
Kathryn Opheim, MD
Iowa | Medicine
CURRENT ISSUES
Futures
Is health system reform a dead issue?
USA Today and other major newspapers
predict the Republican Congress is not likely
to drop health system reform entirely.
Republicans may attempt smaller changes
such as insurance reforms that would ban
denial of coverage for pre-existing conditions,
medical malpractice reform or tax relief for
health care spending.
The White House is also revamping its
approach to reform in the wake of the elec-
tions. The President may fold health reform
into the federal budget next year instead of
sending Congress a massive piece of legisla-
tion. This would give the White House a bet-
ter chance at passing at least part of the plan.
There is talk around Washington that
White House Chief of Staff Leon Panetta will
take over the job of top Clinton advocate for
health system reform legislation this year.
Experts predict that, if health reform does
re-emerge, it could well be in the context of a
broader debate on reducing the deficit —
familiar territory for Panetta.
AMA leaders face congressional panel
AMA leaders faced a congressional panel in
Washington recently, trying to head off a new
round of cuts in Medicare.
“Whether it’s for health reform or deficit
reduction, the result in either case would be
the destruction of Medicare as we and our
patients know it,” said AMA Executive Vice
President James Todd, MD, speaking before
the Physician Payment Review Commission.
According to Dr. Todd, more cuts could leave
Medicare paying just 34% of private payments
by the year 2004.
According to the New York Times, two
issues are likely to dominate the health poli-
cy agenda in this congress — curbing the
growth of Medicare and Medicaid and propos-
als to give states more freedom to pursue
their own health care plans. “These are only
pieces of the national health care debate, but
Republican “Contract with America”
The Republican Contract with America is a
package of 1 0 laws the GOP hopes to pass
during the new congressional session.
Following are contract provisions pertain-
ing to health care.
New expenses
Senior Citizens’ Fairness Act — Includes an
incentive for private long-term care insurance
Cost: $1.3 billion over five years
Proposed spending cuts
Reducing Medicare indirect medical educa-
tion adjustment to 3% from 7.7%
Savings: $13.5 billion over five years
Requiring managed care for Medicaid
Savings: $10 billion over five years
Increasing Medicare Part B premiums for
wealthy beneficiaries
Savings: $7.4 billion over five years
Increasing Medicare Part A deductibles for
wealthy beneficiaries
Savings: $1.7 billion over five years
Requiring 20% co-insurance for Medicare
clinical laboratory services
Savings: $6.2 billion over five years
Source: Modem Healthcare
they are big pieces,” the Times said.
With the collapse of the Clinton plan and
all other federal efforts at reform, states are
clamoring for more authority to tax and regu-
late health benefits provided by companies
operating within their borders. Many states
say they need relief from federal regulation
such as ERISA to carry out plans to expand
coverage and control costs.
A huge debate is expected over caps and
cuts in Medicare and Medicaid, driven by a
desire to reduce the federal budget deficit.
Economic experts say there is no way to bal-
ance the budget and cut taxes unless there
are huge reforms in entitlements. C31
AT A GLANCE
The AMA has proposed
that its Hospital Medical
Staff Section instead be
called the Organized
Medical Staff section.
•
The IMS has available
cassette tapes of excel-
lent presentations by
consultants at the
recent Futures confer-
ence “ Organising for
Change The presen-
tations cover capita-
tion, new physician
arrangements and the
future of managed care
in Iowa. See page 10 for
details on ordering.
The Congressional Bud-
get Office estimates that
medical technology and
intensified use of exist-
ing technology will
account for nearly half
the growth in health
care expenditures from
1995 to 2003. Many
reform plans — includ-
ing the Clinton Plan —
did no t address this
problem, says US News
and World Report
Iowa [Medicine
Legislative Affairs
CURRENT ISSUES
AT A GLANCE
The IMS will sponsor a
Medicine Day at the
Iowa Legislature for
physicians. Alliance
members and clinic
managers Wednesday,
March 22. This will be
an opportunity to
observe the Iowa Leg-
islature in action. A
briefing and luncheon
will be held at the IMS
prior to the trip to the
capitol. For more infor-
mation, call Paul Bishop
at the IMS, 515/223-
1401 or 800/747-3070.
Smoking by American
adults has fallen to its
lowest level since 1941,
down to 26%. However,
smoking among teen-
agers has held steady or
increased. Since 1987,
the smoking rate among
high school seniors has
been inching up.
•
Statewide, the number
of motorcycle fatalities
decreased 37.5% after
introduction of Calif-
ornia’s helmet use law,
from 523 fatalities in
1991 to 327 in 1992.
More legislative priorities approved
Based on the recommendations stemming
from a late November meeting of the IMS
Committee on Legislation, the IMS Board of
Trustees has approved the following addition-
al legislative priorities for this session:
Patient Protection Act (PPA)
The American Medical Association has
developed model state legislation similar to
the Patient Protection Act being advocated
on the federal level. The IMS will work to
implement elements of the PPA with private
sector organizations offering managed care
plans and may use elements of the PPA as a
basis for discussion and negotiation through-
out the legislative process.
Bicycle helmets for children
The IMS supports legislation to require
children to wear protective helmets when rid-
ing bicycles.
Definition of a podiatrist
Iowa Podiatric Society is proposing legisla-
tion to redesignate podiatrists as “podiatric
physicians”. Because the Iowa Code already
includes podiatrists under the definition of a
physician, IMS opposes opening the code to
further amendment.
Definition of surgery
IMS believes surgery should be performed
only by individuals licensed to practice med-
CONTACTING YOUR LEGISLATORS
Telephone number during the session:
Senators 515/281-3371
Representatives 515/281-3221
Governor 515/281-5211
Write to them at:
STATEHOUSE
Des Moines, Iowa 50319
You may also contact your legislators at home
when the legislature is not in session. If you don’t
know who your legislator is or need your legisla-
tor’s home address and phone number, call Lyn
Durante of the IMS staff, 800/747-3070 or
515/223-1401.
icine and surgery, or by those additional cat-
egories of practitioners already specifically
licensed to perform surgical services. The
IMS supports legislation to define surgery,
including the use of lasers in performing sur-
gical procedures.
Statewide trauma system
The IMS supports legislation establishing a
statewide trauma care system as proposed by
the Iowa Trauma Systems Development
Project Planning Consortium. The Consor-
tium includes representatives of the IMS and
other physician organizations. The IMS will
work to include representation by all appro-
priate physician specialties on councils and
committees established by legislation. 021
IMS Position Papers Available to Member Physicians
Position papers on a number of key health issues are available from the IMS public affairs staff.
Call Lyn Durante at 515/223-1401 or 800/747-3070. Additional position papers may be drafted
as issues arise during the session. Currently, papers are available on:
Managed Care, Any Willing Provider Liability Reform CHMIS
Definition of Surgery Organ Procurement Helmet Law
Tobacco Issues Health System Reform Smoker’s Rights
Lay Midwifery (available mid-January)
Iowa [Medicine
CURRENT ISSUES
Medical Economics
CMS is coming July 1, 1996
Senate File 2069, approved and signed by
Governor Terry Branstad on April 1, 1994,
enables implementation of a statewide
Community Health Management Information
System (CHMIS) in Iowa.
This legislation mandates all health care
providers to submit claims electronically and
all payers to accept one uniform claim for-
mat. The CHMIS will also be used as a central
data repository, storing all information sub-
mitted on the IICFA-1500 and UB-92 claim
forms in the first phase of the initiative.
The IMS will present a complete overview
of CHMIS activity in Iowa to groups of mem-
ber physicians. Call Donna Bottorff at the
IMS, 800/747-3070 for more information.
IFMC nominating slate
The Iowa Foundation for Medical Care
(IFMC) Nominating Committee has ann-
ounced its proposed slate for the upcoming
board of directors election.
The IFMC planned to mail ballots early this
month. Voting instructions will accompany
the ballots.
IFMC members will be notified of election
results by mail in mid-February.
All of the MD positions elected by mem-
bers are for three-year terms.
Nominees for county representative director positions:
Michael Crane, MD (Cerro Gordo County)
Koert Smith, MD (Des Moines County)
Karl Larsen, MD (Johnson County)
Jolynn Glanzer, MD (Linn County)
Paul Karazija, MD (Polk County)
Peter Boesen, MD (Polk County)
Gary DeVoss, MD (Pottawattamie County)
Elie Saikaly, MD (Story County)
Nominees for area representative director positions:
John Ellis, MD, District Area I (Johnson,
Muscatine, Scott, Washington, Louisa,
Jefferson, Henry, Des Moines, Van Buren and
Lee).
Stephen Piercy, MD and Steven Sohn, MD,
District Area II (Sac, Calhoun, Webster,
Hamilton, Carroll, Greene, Boone, Story,
Guthrie and Dallas).
For more information about the IFMC elec-
tions, contact William Vanderpool, IFMC vice
president of corporate affairs, 515/223-2170.
In case you haven’t heard . . .
HCFA has designated Iowa as a single
Medicare payment locality with one fee
schedule. The change began January 1.
The original request to be designated as a
single locality came from an Iowa Medical
Society House of Delegates action in 1992
and was spearheaded by a significant number
of practicing physicians.
IMS has supported and coordinated Iowa’s
petition to HCFA because equal Medicare
payments throughout all areas of the state
could attract more physicians to rural Iowa.
Medicaid funding granted
As part of OBRA ’94, the federal govern-
ment directed state Medicaid agencies to pur-
sue a physician based point-of-service claims
processing system. The federal government
will provide funding to Medicaid to enhance
operations and make this possible.
The Department of Human Services and
the Iowa Medical Society are studying the
appropriate methodology to make this system
usable for physicians. Physicians will need
the following equipment:
1 ) a computer with a high speed modem;
2) an arrangement with a network;
3) software for transmitting and receiving
data elements requried on the HCFA- 1500
form;
4) staff with computer skill.
Medicaid is currently in the process of
continued
AT A GLANCE
Federal officials said
medical inflation in
1993 was the lowest in
seven years. HCFA says
Americans spent an
average of S3, 299 each
on health care, S205
more than 1992. This
7.8% increase was the
lowest since 1986.
•
A study in JAMA says
physicians could reduce
chances of being sued
for malpractice by not
acting rushed or being
impersonal.
•
New Jersey, which pays
the third highest Med-
icaid rates in the nation,
plans to cut by 20% the
amount of money hospi-
tals receive to care for
Medicaid patients.
Iowa | Medicine
CURRENT ISSUES
Medical Economics
continued
designing the proposed system. Input from
physician groups will be appreciated. Gall
Donna Bottorff at the IMS, 800/747-3070, for
more information or to comment.
State health contract awarded again
Iowa welfare officials announced they will
award a disputed 8100 million state contract
for mental health management to a California
firm that was runner-up last summer in com-
petition for the state’s business, according to
a recent story in the Des Moines Register.
Last June, the state announced it had cho-
sen Value Behavioral Health Inc. from among
eight bidders for the mental health managed
care contract.
Medco, the California firm which has now
been awarded the contract, was runner-up in
the bidding last summer but then filed a law-
suit alleging a flawed selection process. A
Polk County judge found in favor of Medco,
citing “overwhelming circumstantial evi-
dence of impropriety”. lie ordered Value dis-
qualified from bidding.
Don Herman, the Iowa Department of
Human Services administrator in charge of
the Medicaid program, said the mental health
initiative will take place in September.
Less aggressive regulation
The Kiplinger Newsletter is predicting that
federal regulators will be less aggressive
because of the election.
“Republican-led congressional committees
will lean hard on regulators to take it easy on
rulemaking or risk losing a chunk of their
budgets,” said Kiplinger.
The government may drop a plan to hold
employers responsible for making their dri-
vers buckle up. Instead, employees will be
held personally liable.
OSHA plans to propose new rules for repet-
itive motion injuries this year, but Congress
will ask that small businesses be exempt and
will demand proof that using computers can
cause wrist injuries.
Physician, dentist federation in Florida
The Associated Press reported that a newly
formed Federation of Physicians and Dentists
in Brevard County, Florida plans to challenge
antitrust laws prohibiting collective bargain-
ing by physicians. The group, which has 100
members, also plans a public relations cam-
paign against what it calls restrictive rules
and regulations.
“The AMA recognizes that managed care
has both advantages and disadvantages,”
commented Nancy Dickey, MD, AMA vice
chair. She said there are several physician
groups who are “more activist than a tradi-
tional organization affords them.”
Meanwhile, the Florida Medical Associa-
tion’s legal counsel advised the physicians to
exercise extreme caution about joining “the
union”, warning that the FTC or Justice
Department could step in if they try to bar-
gain collectively.
Deere pushes up deadline
John Deere has sent a letter to all of its
health care providers asking that claims be
submitted electronically no later than
January 1, 1995. In the letter, Deere officials
said this will be a contractual requirement by
January 1, 1996.
Provisions for implementation of CIIMIS
require that all physicians submit electronic
claims by July 1, 1996.
Legal reforms proposed by Republicans
Republicans are expected to propose a
number of legal reforms during the first 100
days of the congressional session, but quick
action is unlikely, experts predict.
Among initiatives to be introduced are
“loser pays” product liability and malpractice
and punitive damage limits.
Trial lawyers and consumer groups will
gear up to block action.
Meanwhile, 20 million civil lawsuits will
continue to be filed each year in the U.S. [HI
Iowa I Medicine
CURRENT ISSUES
Practice Management
1995 CPT update
The CPT 1995 Code Update and the CPT
’95 books have been released. Because it is
essential to have the most up-to-date CPT
information, be sure to get the ’95 book soon.
The information in the introduction and
in the E & Management guidelines at the
front of the book is invaluable. The guidelines
under each of the six sections and numerous
subsections should also be studied carefully.
There are significant changes in the pre-
ventive medicine services area:
Codes 9938T99397 can now be used for patients
with chronic illnesses and problems. If there is an
insignificant or trivial problem which does not require
additional work, include it in the preventive code.
However, if an abnormality is encountered or a
preexisting problem addressed in the process of per-
forming this preventive medicine E/M service and if
it is significant enough to require additional work,
office/outpatient codes 99201-99215 should also
be reported. Modifier 25 should be added to the
office/outpatient code to indicate a significant E/M
service was provided by the same physician on the
same day as the preventive medicine service.
Codes 99281-99397 include counseling etc.
which are provided at the time of the initial or period-
ic comprehensive preventive medicine examination.
Counseling codes 99401-99412 are to be used for
counseling, etc. sessions provided at an encounter
separate from the preventive medicine examination.
There are also significant changes in emergency
department coding, cardiac catheterization proce-
dures and physical medicine.
A comprehensive list of CPT revisions is
found in the appendices of the CPT ’95 books.
Detailed code changes are provided in
numerical sequence in the “CPT Assistant”,
Volume 4, Issue 4 — Winter, 1994, for a cost of
$21.25 for AMA members. Order from the
AMA by calling 800/621-8335.
HCFA E & M Code documentation
Since the IMS Services E & M Coding sem-
inars in November, there have been the fol-
lowing changes in the final guidelines:
1. Chief Complaint: strike out as indicated:
The CC is a concise statement describing the
symptoms, problems, condition, diagnosis,
physician recommended return or other fac-
tor that is the reason for the encounter, usu
ally stated in the patient’s words. —
2. Past and/or Social History: change the
first full paragraph to: For the categories of
subsequent hospital care, follow-up inpatient
consultations and subsequent nursing facility
care, CPT requires only an “interval” history.
It is not necessary to record information about
the PFSH.
3. Documentation of Examination: delete
the fifth documentation guideline: When a
pelvic or rectal examination i-n-an adult is
deferred, the reason! s) should he documentedr
4. Amount and/or Complexity of Data to
be Reviewed: modify the second documenta-
tion guidelines as indicated: The review of
lab, radiology and/or other diagnostic tests
should be documented. A simple notation
An entry in a progress note such as “WBC ele-
vated” or “chest x-ray unremarkable” is
acceptable.
Watch for more guideline changes in next
month’s Practice Management section. 03
Practice Management Workshops for You
Because of the overwhelming response and requests for additional programs on the new HCFA E & M service
documentation guidelines, we will present additional programs (including information on the CPT Update) in
January at the following locations throughout Iowa: SPENCER, COUNCIL BLUFFS, DES MOINES, BURLINGTON,
IOWA CITY, WATERLOO, OTTUMWA AND MARSHALLTOWN.
Watch for a mailing on the sites and dates. We are also available for local programs at your selected site.
Please contact Mary Reinsmoen at IMS Services, 515/223-1401 or 800/728-5398 for additional information.
AT A GLANCE
IMS members can now
save more than ever
when they ship as few
as 10 letters or pack-
ages each month via
Airborne Express. Mem-
bers pay only S8. 75 for a
standard eight-ounce
overnight letter express
when they send a mini-
mum of 10 shipments
monthly. Also, physi-
cians can save even
more when they deposit
their shipments in the
Airborne Drop Box, pay-
ing at most S7.50 for an
eight ounce overnight
letter express. For more
information on the new
rate structure for IMS
member physicians, call
1/800- MEMBERS.
Mention you are a mem-
ber of the IMS.
♦
A new Iowa law requir-
ing all employers to offer
access to health insur-
ance to all employees
was scheduled to go into
effect January’ 1, but as
of press time, the state
had not issued final reg-
ulations. Watch future
issues of Iowa Medicine
for more information.
Iowa | Medicine
CURRENT ISSUES
Practice Management
continued
Two issues that
demand dose
attention are
patient abandon-
ment and handling
of medical records.
Midwest Medical Insurance Company Focus on Risk Management
Issues to consider when retiring
or leaving a practice
Physicians contemplating retirement or
a change in practice face many important
issues. Two areas that demand close atten-
tion are the issues of patient abandonment
and the handling of medical records.
•When retiring or leaving one practice
for another, notify patients well in
advance. The Iowa State Board of Medical
Examiners recommends a minimum of 30
days’ notification.
•Put a notice in the office and in a pub-
lication of general circulation. Include the
date of the change in practice or closing
and indicate that patients may have copies
(always maintain originals) or their med-
ical records transferred to the physician of
their choice. Or, you may wish to identify
the location where copies may be
obtained.
•Send a letter to active patients with
the aforementioned information. Stress
the importance of follow-up care. Include
an authorization for the release of medical
records.
•If retiring from practice, maintain
original records indefinitely by using a
storage facility, microfilm or caretaker to
assume responsibility for the medical
records. Identify the caretaker in your
notice to patients.
For further information, contact Lori
Atkinson, MMIC risk management coordina-
tor, MMIC West Des Moines office, PO Box
65790, West Des Moines, 50265, 800/798-
9870 or 515/223-1482.
When you offer patients a more convenient payment method,
you end up with more patients.
Iowa Medical Society brings you the Professional Services Account' from MBNA America.
Now there is a credit card acceptance program
that enables you to successfully balance the financial
demands of your professional practice with your
patients’ desire for convenient payment alternatives.
The Professional Services Account® from MBNA America.
MBNA, one of the nation’s leading credit card
issuers, designed this program specifically for profes-
sional practices. It has earned the endorsement of the
Iowa Medical Society as an ideal way to stabilize cash
flow while providing patients with today’s most
accepted and affordable method of payment.
Offer your patients the convenience of an
alternative payment option.
A Professional Services Account from MBNA will help
make your services more accessible to your current
patients and more affordable to new ones.
Protect your bottom line by increasing cash flow
and reducing expenses.
With an MBNA® Professional Services Account,
payments are credited to your deposit account at your
local bank within 48 hours from the time your receipts
are received by MBNA. There’s no need to wait for
your funds or to spend time and money on additional
billings. Furthermore, because MBNA offers a low rate,
you can realize a better return on each charged trans-
action. And you’ll even be able to customize the pro-
cessing method and deposit option to meet your
professional practice and personal financial needs.
Contact MBNA America about a Professional Sendees Account.
Call 1-800-526-8286
Monday through Friday from 8 a.m. to 8 p.m., and
Saturday from 8 a.m. to 5 p.m., Eastern time
VISA
MBHK
IMS
MBNA America? MBNA? and Professional Sendees Account are federally registered service marks of MBNA America Bank, N.A,
MasterCard* is a federally registered service mark of MasterCard International, Inc., used pursuant to license. Visa* is a federally registered servicemark of Visa U.S.A, Inc., used pursuant to license.
©1994 MBNA America Bank, N.A. AD 9'2571'94
Iowa | Medicine
CURRENT ISSUES
Newsmakers
Surplus or restorable equipment needed New members (as of September 1994)
Dear Editor:
During November I was privileged to partici-
pate in a program with an organization known
as Doctors of the World. I was assigned to the
province of Kosovo, the southernmost area of
what was formerly Yugoslavia. The main agenda
in the area is to facilitate the immunizations of
150,000 children —
the programs had been
suspended for several TT ^
years due to philo- Jut/lLCl
sophic differences i
between the two eth- LO U IL
nic groups in the area.
The second mission is
to improve and treat
tuberculosis which is rampant both for chil-
dren and adults. These programs obviously
require months, if not years, for a solution.
Infant mortality and tuberculosis rates are
the highest in Europe. Enteric disease, dehy-
dration and sepsis are aggravated by
malnutrition and crowded living conditions.
Shallow wells as a source of water where no
sanitary facilities exist and very heavy smoking
habits contribute to this poor quality of life.
I spent several days with village doctors who
were fascinated with my otoscope and ophthal-
moscope. As a result, I taught them what can be
seen and diagnosed. They do not have any hope
of buying anthing like that in their lifetimes.
Similarly, the Pulmonary Hospital in Pristhina,
the capitol of Kosovo, does not have a
brochoscope, even though several of the staff
are listed as pulmonologists.
If any readers have access to surplus or
restorable equipment such as described above,
please write: Ms. Abbe Stoddard, Secretary,
Doctors of the World, 625 Broadway, 2nd Floor,
New York, New York 10012. The telephone
number is 212/529-1556.
Your help to fellow doctors would be appre-
ciated. It is great to live and practice medicine
in America. — Robert McCool, MD, Clarion
Cedar Rapids
Mario Mota, MD, ophthalmology
Loren Mouw, MD, neurosurgery
Mathew Reid, DO, emergency medicine
George Walker, MD, emergency medicine
William Witcik, MD, cardiology
Chariton
Greg Cohen, DO, family practice
Cherokee
George Ide, DO, psychiatry
Columbus Junction
David Bedell, MD, family practice
Council Bluffs
Clifford Boese, MD. orthopaedic surgery
Chitrita Roy, MD, pediatrics
Davenport
Anis Ansari, MD, internal medicine/nephrologv
Lisa Davis, MD, family practice
Randy Gripple, MD, orthopedics
James Hansen, MD, pulmonary diseases
Carolyn Martin, MD, obstetrics/gyneeology
Joseph Martin, MD, orthopedic surgery
Thomas MeKav, MD, urology
Michael Netzel, MD, allergy/immunology
Carlos Rodrigues, MD, obstetrics/gynecology
Richard Syfert, DO, obstetrics/gynecology
Decorah
Harold Amsbaugh, MD, anatomic/clinical pa-
thology
Awards, appointments, etc.
Dr. Dale Roberson, Cedar Rapids, has been
named a fellow of the American College of Radiol-
ogy. Dr. Corrine Ganske, Des Moines, has been
named associate director of the family practice
residency program at Iowa Lutheran Hospital. EE]
AT A GLANCE
This special issue on
domestic violence was
initiated by the IMS Do-
mestic Violence Task
Force. Members include
Drs. Rebecca Wiese,
chairman, Deborah
Reisen, Francis Garrity,
Dale Wassmuth and Jan
Bannister (IMS Alliance) .
•
Dr. John Rhodes, Jr.,
Pocahontas family phy-
sician, is participating in
the American Medical
Association’s study of the
organized medicine fed-
eration.
If Your Jeweler
Is Not A Member
Of
You May Want
To Ask Why.
The American Gem Society is a group
of distinguished jewelers in North
America that’s dedicated to consumer
protection. As a member, Josephs has
always adhered to the highest standards
of ethics and gemological knowledge.
Only at Josephs will you find sixteen
American Gem Society registered jewelers
and certified gemologists to serve you.
If you’re considering a diamond or other
fine jewelry purchase, buy from a jeweler
you can truly trust. Buy from Josephs —
an AGS member jeweler.
Family Owned Since 1871
Sixth at Locust Merle Hay Mall Valley West Mall
515-283-1961 515-276-1521 515-223-6044
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NEW YORK CITY
YOCON'
YOHIMBINE HCI
Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car-
boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees.
Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine
alkaloid with chemical similarity to reserpine. It is a crystalline powder,
odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine
Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors Its
action on peripheral blood vessels resembles that of reserpine, though it is
weaker and of short duration. Yohimbine’s peripheral autonomic nervous
system effect is to increase parasympathetic (cholinergic) and decrease
sympathetic (adrenergic) activity, it is to be noted that in male sexual
performance, erection is linked to cholinergic activity and to alpha-2 ad-
renergic blockade which may theoretically result in increased penile inflow,
decreased penile outflow or both.
Yohimbine exerts a stimulating action on the mood and may increase
anxiety. Such actions have not been adequately studied or related to dosage
although they appear to require high doses of the drug . Yohimbine has a mild
anti-diuretic action, probably via stimulation of hypothalmic centers and
release of posterior pituitary hormone
Reportedly, Yohimbine exerts no significant influence on cardiac stimula-
tion and other effects mediated by B-adrenergic receptors, its effect on blood
pressure, if any, would be to lower it; however no adequate studies are at hand
to quantitate this effect in terms of Yohimbine dosage.
Indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may
have activity as an aphrodisiac.
Contraindications: Renal diseases, and patient's sensitive to the drug. In
view of the limited and inadequate information at hand, no precise tabulation
can be offered of additional contraindications
Warning: Generally, this drug is not proposed for use in females and certainly
must not be used during pregnancy. Neither is this drug proposed for use in
pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer
history. Nor should it be used in conjunction with mood-modifying drugs
such as antidepressants, or in psychiatric patients in general.
Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a
complex pattern of responses in lower doses than required to produce periph-
eral a-adrenergic blockade. These include, anti-diuresis, a general picture of
central excitation including elevation of blood pressure and heart rate, in-
creased motor activity, irritability and tremor. Sweating, nausea and vomiting
are common after parenteral administration of the drug.1-2 Also dizziness,
headache, skin flushing reported when used orally.1-3
Dosage and Administration: Experimental dosage reported in treatment of
erectile impotence. 1 -3-4 1 tablet (5.4 mg) 3 times a day, to adult males taken
orally. Occasional side effects reported with this dosage are nausea, dizziness
or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3
times a day, followed by gradual increases to 1 tablet 3 times a day. Reported
therapy not more than 10 weeks.3
How Supplied: Oral tablets of Yocon» 1/12 gr. 5.4 mg in
bottles of 100's NDC 53159-001-01 and 1000'
53159-001-10.
References:
1. A. Morales et al. , New England Journal of Me
cine: 1221 . November 12, 1981 .
2. Goodman, Gilman — The Pharmacological ba:
of Therapeutics 6th ed., p. 176-188
McMillan December Rev. 1/85.
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales et al. , The Journal of Urology 1 28:
45-47, 1982.
Rev. 1/85
AVAILABLE AT
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PHARMACEUTICALS, INC.
64 North Summit Street
Tenafly, New Jersey 07670
(201 )-569-8502
1 -800-237-9083
Iowa I Medicine
DOMESTIC VIOLENCE ISSUES
Break the silence,
Begin the cure
Between January of 1990 and January of
1994, at least 30 Iowa women were mur-
dered by their husbands or partners. Many
more are battered each year and it is
believed there are victims of domestic vio-
lence in the patient population of nearly
every Iowa physician.
In May of 1994, the Iowa Medical Society
Board of Trustees appointed an IMS Task
Force on Domestic Violence. Though the
O.J. Simpson case subsequently brought
this issue to the forefront, the IMS Board
was following the lead of current AMA
President Robert McAfee, MD, who has
made spouse/partner battering the focus
issue of his presidency.
Seventy-five percent of partner battering
victims seek treatment for immediate or
long-term effects of abuse. However, physi-
cians intervene in only 5-10% of suspected
cases. Many survivors say they would have
been more likely to discuss the abuse with
their physician than anyone else.
Dr. McAfee believes physicians realize
they could do more to help but don’t have
enough information to feel comfortable
doing so. Perhaps physicians do not have an
open avenue of communication with other
professionals who might offer assistance.
The IMS Task Force on Domestic
Violence, chaired by Rebecca Wiese, MD, a
Davenport family physician, decided physi-
cian education is the first responsibility of
the IMS. Last fall, the task force recom-
mended a comprehensive educational plan
to be completed by April. Two special
issues of Iowa Medicine are part of that
plan. Other components are an education-
al videotape and accompanying handbook
for physicians and posters, patient infor-
mation pamphlets and hotline cards
designed for distribution by physicians.
The logo for this project, seen on this
month’s cover, was designed by IMS
Alliance President Barbara Bell. The bird
breaking free of the granite block symbol-
izes victims of domestic violence breaking
free of the tyranny of abuse.
On the following pages, you will find
articles designed to raise your clinical
knowledge of partner battering — informa-
tion you can use to assist victims you
encounter in your practice. There is an
article on finding the right words to talk to
patients about abuse. Articles by coun-
selors explain why victims stay in abusive
relationships and why batterers batter.
There is an interview with a survivor of
domestic abuse who was nearly killed by
her husband. In the scientific section, look
for articles on the effects of domestic abuse
on children and the root causes of violence.
Begin the Cure
“The doctor who
taSked to me
so respectfully
doesn’t know to
this day how much
he helped me.”
DOMESTIC ABUSE
SURVIVOR
Coming in the February Issue of Iowa Medicine
•Domestic abuse intervenion — what
works, what doesn’t work
•Special problems of battered women in
rural Iowa
•Physicians’ legal responsibilities, liability
concerns
•Local resources for physicians, including
an Iowa map of shelters
•Patient insert with a message from Laurie
Schipper, executive director of the Iowa
Coalition Against Domestic Violence
IowalMedicine
Iowa Domestic
Abuse Hotline
1/800-942-0333
Iowa Coalition
Against Domestic
Violence
515/281-7284
Next month
In the February Iowa
Medicine, watch for a
map of Iowa domestic
abuse shelters and
complete information
on services offered
locally around Iowa.
Finding die right words
Though most battered women eventually leave the abusive relationship, the process of
leaving can take months or years. This can be frustrating for physicians who want to help
their patients and don’t understand why the woman seems to prefer living with her abuser.
David Moen, MD, a physician practicing at the Fairview Riverside Emergency Department
in Minneapolis explained it eloquently: “I saw these women as non-compliant patients. I
told them to leave their situations, but they didn’t do what I said. They didn’t seem to want
my help and it made me angry.”
Then, a coworker was murdered by her husband and Dr. Moen saw partner battering in
an entirely different light. He contacted a domestic violence shelter and set up a meeting
with eight women staying there. lie learned that most women don’t admit abuse to physi-
cians because they are either embarrassed or afraid of retribution if someone finds out.
“I learned not to let anger influence the care I give patients,” Dr. Moen said. “The single
most valuable piece of advice I have for physicians is not to feel you have failed if the
woman denies she has been abused or returns home.”
Dr. Moen believes that treating the victim with respect and dignity is the most important
thing a physician can do and this opinion is validated by women who have survived domes-
tic abuse. As one survivor put it, “Physicians have much more influence than they realize.
With just a word or a phrase, you can give the woman the message that she doesn’t deserve
to be abused and that you respect her even though she has been abused. This plants a seed
that may bear fruit later.”
Experts in domestic abuse explain that victims feel trapped, embarrassed and afraid of
their batterer. They feel responsible for the abuse and their self-esteem is lowered by
repeated failed attempts to stop the violence. Keep in mind that most patients won’t tell you
they are being abused. You must ask.
High risk groups (patients who should be asked about domestic violence)
1. Pregnant women — 25-40% of women who are battered are battered during pregnan-
cy. These women have twice the miscarriages of control groups and are four times more
likely to deliver low birth weight babies.
2. Injured women in emergency departments — 20-35% of women with acute injuries
in the emergency department have been hit. Highest risk injuries are to the face, neck,
chest, abdomen and pelvis areas.
3. Suicide attempts — 24% of all suicide attempts are preceded by an episode of domes-
tic abuse. Fifty percent of suicide attempts by black females are preceded by assault.
4. Depressed women — Approximately 25% of battered women report that at some time
during their abusive relationship they were treated for depression.
5. Chemieaily-dependent women — Battered women are four times more likely to be
chemically dependent.
DOMESTIC VIOLENCE ISSUES
6. Women with insomnia, eating disorders, migraines, nonspeeifie pain — These could
be signs a woman is living with the stress of an abusive relationship. These signs usually
present in a primary care setting.
7. Women who repeatedly miss or caneel appointments — AMA President Robert
McAfee, MD, suggests flagging a woman’s chart if a male calls and cancels her appointment.
Questions and responses
Experts in domestic abuse recommend asking direct, simple questions if you suspect
partner battering. Following are examples:
1. For patients with suspicious injuries
“That bruise looks painful. Did someone hit you?”
2. For depressed patients, suicide attempts or other complaints which raise red flags
“Sometimes people feel this way when someone in their life is trying to control what
they say or do. Do you think this happens to you?”
3. What to say when the patient answers “no”
“ I’ve seen people who are afraid or embarrassed to tell me they’ve been hit. I under-
stand. I just want you to know that if you are ever hurt it’s okay to tell me about it. This
is a safe place to come and talk about it. ”
4. What to say when the patient answers “yes”
“ I’m glad you told me. Sometimes people are afraid to talk about it. Are you in a rela-
tionship with this person?”
“ You don’t deserve to be treated this way. Getting out of these relationships isn’t easy,
but help is available. ”
It is also a good idea to ask if the patient feels safe going home, if she feels suicidal or if
the abuser has a weapon. If the patient wants help, find out if she is aware of community
support or would like you to call the domestic abuse hotline for Iowa (1/800-942-0333).
5. What to say if the patient appears offended
“ I’m sorry, I didn’t mean to offend you. I’ve seen many women with injuries such as
this that are caused by hitting. Most women won’t tell me unless I ask. ”
Physicians shouldn’t try to do it alone
Partner battering is a complex problem and physicians should never feel they must solve
it all alone in one patient visit. Domestic violence requires an interdisciplinary approach.
Here are some tips from experts on making your office a physically and emotionally safe
place for victims of abuse:
•Enlist coworkers to do this work with you.
•Educate all staff on domestic violence issues and local resources.
•Design a domestic abuse protocol for emergencies in your office.
•Develop a consulting relationship with your local shelter or intervention project.
•Display posters and pamphlets in your reception area and examination rooms.
Physicians
should not feel
they have failed if
the woman denies
she has been
abused and
returns home.
Physician survey
Test your knowledge
of domestic abuse
diagnosis and other
domestic abuse issues
by completing the
survey in the center
of this magazine.
Please return the
survey to the IMS
to help us determine
future educational
efforts.
IowajMedicine
Violence begins
subtly. Hiss makes
it difficult
to identify
the behaviors as
they escalate and
her fear increases.
Kay Maher-Sharp
Ms. Maher-Sharp is a
counselor at the Family
Violence Center in De s
Moines and coordinates
the Center’s First
Responder program. This
program is staffed by
volunteers who are
available to respond to
victims of domestic vio-
lence 24 hours a day.
Why do they stay?
In Iowa, between 20,000 and 44,000 women are abused in their homes each year.
Domestic violence results in more injuries requiring treatment than rape, car accidents and
muggings combined. Battered women are twice as likely to miscarry. The annual cost of
treating domestic violence injuries in the U.S. is between $ 5 and $10 billion. Yet, only one
in 25 battered women seeking treatment is identified as being abused.
Physicians are in a position to play an integral role in ending the cycle of violence. By
becoming aware of the dynamics of domestic violence, they can help their patients seek
appropriate assistance.
Often, the violence begins subtly. This makes it difficult to identify the behaviors as they
escalate and her fear increases. Using coercion, threats, intimidation, emotional abuse,
denying, blaming, isolation, economic abuse and the children as weapons, the abuser tears
down her self-esteem. He has isolated her from family, friends and/or the community. He
denies responsibility and treats her as subservient.
Battering is a conscious choice
Domestic violence is not a mental illness, nor is it caused by substance abuse — although
this may intensify it. This is a conscious choice the batterer makes as a way to control
another person because it is effective.
Battered women leave and return to the relationship an average of seven to nine times,
and what they are actually doing is leaving the relationship in stages. She usually doesn’t
leave the first time because the violence is a new experience and he promises it will never
happen again. As the violence escalates, she may leave for a few days or even weeks — for
safety and to teach him a lesson. As the violence escalates further, he has established such
fear in her that leaving may seem more dangerous than staying.
Statistics prove this feeling is justified — women face a 75% greater chance of being
killed when they try to leave. Also, she may doubt her ability to provide for herself and her
children. She may face poverty (50% of homeless people are battered women and their chil-
dren). Religious beliefs may also be a factor keeping her in the marriage. Finally, since
domestic violence is an ongoing pattern, the abuser has created constant barriers which
prevent the victim from ending the relationship.
Look for stress-related symptoms
Due to the large number of battered women in Iowa, every woman who comes to you for
care should be screened. Remember that when a battered woman comes in for medical
treatment, it may be her way of reaching out for help.
If physicians look only for evidence of physical trauma, a majority of battered women
will go unrecognized. Instead, look for stress-related symptoms such as the following:
DOMESTIC VIOLENCE ISSUES
•chronic headaches •shortness of breath •chest pain
•depression •insomnia •injuries during pregnancy
•substance abuse •suicide attempts •frequent visits with vague complaints
•constant weight gain or loss •gynecologic problems (frequent infections)
She’s not non-comp! iant, she’s afraid
Battered women are often viewed hv physicians as non-compliant patients. It is impor-
tant to remember that it may not be safe for her to disclose how she got her injuries or how
she is being treated at home. She has been ordered by her partner not to talk about “per-
sonal matters” and has been conditioned that the abuse is her fault. Society’s reaction to
abused women often reinforces this conditioning.
Medical professionals are in a position to break through the patient’s denial. Many women
do not even realize they are being abused. Part of her survival mechanism may be to mini-
mize the abuse and disassociate from her own body. She may not even be fully aware of all
her injuries. You can help her recognize abusive behavior in the relationship and let her
know you are concerned for her safety., Explain very specifically why you are concerned.
When you question her about abuse, try to get an accurate picture of the violence.
Other important clues
Don’t miss these other red flags that you may be facing
an abused woman:
•She may “over explain” or justify herself.
•She may be very apologetic for taking your time.
•Iler injury may be inconsistent with her explanation.
•Her partner may be demanding or overly protective.
It is extremely important for her safety to talk to her
alone. There is little chance she will tell the truth or give
any accurate information if her abuser is present.
Physicians can use a variety of tactics to get the abuser
out of the room, such as saying you wish to examine her
in private or asking him to go and fill out patient infor-
mation sheets.
Rather than beginning by asking about a particular
injury, ask about the dynamics of her primary relation-
ship. Talk to her in hypothetical “iPwlien” terms if she
will not disclose the truth. Questions may include:
•“Are you ever afraid at home?”
•“Does your partner force you to have sex?”
• “Does your partner threaten you ? ”
•“Does your partner destroy your property? ”
FEELINGS AND DEFENSES OF BATTERED WOMEN
^°IS S3Ud3°
Iowa [Medicine
B}? providing
©pti@iis in a
sensitive,
nonjudgmental
manner, you are
laying the
groundwork for
haltered women
and their children
to live free of
violence.
‘Tve been
bluffing
all my life.
Self-esteem?
I had none.”
Christine Clark
Ms. Clark is director
of communications for
the Iowa Medical
Society and editor of
Iowa Medicine.
By normalizing her situation and not acting shocked by what you see or hear, the physi-
cian may help her recognize she is not alone and therefore feel safer in disclosing. By pro-
viding options in a sensitive, non-judgmental manner, you are laying the groundwork for
battered women and their children to live free of violence. This also empowers victims of
domestic violence to make the decisions that are best for them. Support her decisions and
recognize that she is the expert in her own situation.
Documentation of your observations and the exact statements made by the patient is crit-
ical. This may be her only record of violence and may be very helpful for her in the future
in custody or divorce proceedings.
There is no reason for physicians to be alone in helping abused patients. There are many
local options for referral. In some communities, representatives for various domestic abuse
projects are happy to come to your office or to the hospital to talk to the patient. Bringing
the services to her may be the only opportunity to reach some patients.
There is no easy cure for domestic violence. Physicians are on the front lines in identify-
ing victims. By advocating for battered women and providing them with as many options as
possible, their ability to take steps toward becoming a survivor — rather than a victim —
will be greatly enhanced.
In the time it took you to read this article, 100 women were abused across the U.S. Thank
you for your willingness to learn how to become part of the solution.
A survivor’s stoiy
Editor's note: The names of the people mentioned in this article have been changed.
Linda’s relationship with her husband began with flowers and compliments. It ended
when he nearly beat her to death with a pool cue.
During the 12 years in between, Linda was manipulated, degraded, stalked and terrorized
in a relationship that was stressful at best and nightmarish at worst. Friends and coworkers
warned that John was going to hurt her, hut she didn’t — or couldn’t — believe them.
“I’ve been bluffing all my life,” admits Linda, a tall, attractive woman with a matter-of-
fact demeanor and no trace of self-pity in her voice. “Self-esteem? I had none.”
Raised in a home where she suffered long-term physical abuse at the hands of her step-
father, Linda became pregnant at age 16 and dropped out of high school to marry the child’s
father. Though her first husband didn’t abuse her physically, she left him because he was
emotionally abusive and a bad influence on their children.
Despite having two babies, she managed to earn her GED and graduate from LPN school.
She met John — a nursing assistant — during new employee orientation at a Des Moines
hospital. Though she had no wish to become involved, John — who Linda says could be
“very charming” — wooed her with subtle persistence and eventually won her over.
“Even though you have some of the worst times of your life with an abuser, the thing that
makes it hard is that you’ve also had some of the best times of your life with him,” she says.
Linda’s relationship with her mother was already strained because of her mother’s refusal
to acknowledge her husband’s abusive behavior toward Linda. When Linda married John —
who is Black — her mother cut off all ties, leaving Linda with no family support.
DOMESTIC VIOLENCE ISSUES
Almost as soon as they were married, John began a campaign of brainwashing, put-downs
and mind games. Despite the fact they had three children together, John worked only spo-
radically while Linda had two and sometimes three jobs.
“I was very good at nursing,” she says with pride.
During one of her separations from John, she even managed to go back to school again
and earn her RN. Meanwhile, John’s behavior became more and more vicious. lie became
addicted to cocaine and slept with other women. He often chased her around the house,
throwing objects such as coffee cups at her. Several times, she left him. Each time, he began
stalking her and she would eventually go back to him.
“He followed me everywhere. One night, he loosened all the lugnuts on one of my tires.
Another time, he beat my car with something and totally destroyed it,” she relates. “Every
time I looked out the window, he’d be there in his car watching me.”
Throughout her second marriage, Linda’s weight fluctuated wildly, a sign of the stress
under which she was living. “I hated to come home from work,” she recalls. “I never knew
what I would find.”
She went to a female physician who prescribed diet pills and tranquilizers but didn’t ask
about possible abuse. “I think the fact that I’m an RN worked against me. I guess people
assumed I had control.”
Linda gained almost no weight during her fourth pregnancy because she vomited con-
stantly. Then, early in 1992, John hit her for the first time.
“I thought he’d broken my jaw. I’d always told him I could put up with everything else
he dished out, but that I wouldn’t tolerate it if he hit me. Do you redraw that line?”
Linda called the police and John went to jail. After that, Linda sought outside help to
make her marriage work, including drug rehabilitation for John and couples counseling.
Nothing helped. “I never told the truth to a counselor when John was there. I was too afraid.”
Then, last May, John hit her son and Linda obtained a ‘no contact’ order from juvenile
court. John left their home, which was across the alley from his mother. He began sleeping
in his car in his mother’s back yard so he could watch Linda. Linda’s landlord refused to
change her locks, so she wedged a knife in the door each night. Then, on July 1, she awoke
at 6:30 a.m. and John was in her bed, choking her with a pool cue.
“He said ‘I’m O.J. and I’m going to kill you’,” she reveals. Using the pool cue as a bat, he
beat her in the head, knees and throughout her body. At one point, her 10 year-old son
came in the room. He eventually stopped beating her and left and a neighbor called for help.
Linda was hospitalized for three days with a severe concussion, head lacerations and
other injuries; John was put in jail. He was charged with attempted murder and was unable
to make bail. Six months later, she still has bruises and is suffering from crepitus on her
knees. At the time of this interview, Linda had just learned that a judge dismissed the
attempted murder charge against John, finding him guilty of willful injury.
“The judge said John chose to stop beating me, and that means he’s not guilty of attempt-
ed murder,” Linda says. “My doctor says he stopped because he wore himself out.”
John will probably be out of jail in two years and Linda freely admits she is afraid of him.
“I don’t think he’ll forget about this by then. I think he’ll be even angrier,” she comments.
Linda offers this advice to physicians faced with victims of domestic abuse. “Ask specif-
ic questions but never judge. And never forget the shame women feel — it’s very real. The
last thing we need is someone giving us easy answers.” E]
“I think the fact
I’m an RN worked
against me.
I guess people
assumed I had
control.”
Iowa [Medicine
Who are the batterers?
It is estimated that between 85-95% of domestic violence perpetrators are male.
Although some women are arrested and convicted of domestic assault, this article focuses
on males as perpetrators and their intimate female partners as victims.
Domestic violence, or battering, is defined as a pattern of abusive behavior which
includes physical assault, threats and intimidation, emotional abuse, sexual abuse and iso-
lation of the victim. This expanded definition is important since society typically may
excuse the assailant’s violent behavior as a direct result of alcohol/drug use, “bad temper”
or a response to the victim’s behavior.
What often isn’t recognized is that the violent incident is part of a pattern of behaviors
designed to gain power and control over the partner. Many of these other behaviors, while
not illegal, result in significant psychological damage to the partner and children.
Dale Chell
Mr. Chell is the supervi-
sor for Domestic Abuse
Intervention Services, a
program of Children and
Families of Iowa. He also
serves on the Iowa
Department of
Corrections Batterers’
Committee.
Characteristics of batterers
Although abusive men come from a variety of backgrounds, races and occupations, there
are common characteristics. Rigid sex role stereotypes are pervasive as abusive men
attempt to place their partners in a submissive role. Because of the men’s insecurity, jeal-
ousy and possessiveness are characteristics often manifested in interrogating and stalking
behavior. Other characteristics include low self-esteem, emotional dependency on their
partners, a history of violence in their family of origin and, most importantly, a perceived
need to control their partners. These characteristics are based on their ingrained and
unhealthy beliefs about men’s and women’s roles, intimate relationships and violence.
Those who abuse power are likely to justify behavior that keeps them in control and
focuses attention away from themselves. The three most common obstacles that prevent
men from taking responsibility for their abusive behavior are: blaming others, minimization
and denial.
Often, violent men blame others (or something else) for their behavior. “She made me
hit her” or “I hit her because I was drunk” are common excuses. Blaming is often used to
reinforce his belief that his only option is to use force. The self-defense or retribution
excuses (“I hit her so she would stop hitting me” or “She hit me first”) fit in this category.
By blaming his partner, he attempts to achieve three goals: 1) he presents himself as the
‘good guy’ and protects his positive image; 2) he shifts responsibility for his behavior, in
other words, when she changes the abuse will stop; and 3) he avoids any guilt or shame that
would make him feel bad about himself.
Minimization of the significance and effects of the abuse is another common response of
batterers. Batterers may use words and phrases such as only, just, merely, a little, hardly,
barely, all I did was and she bruises easily. What may be described by a batterer as “a poke
in the chest” may in reality be a punch which caused a severe bruise. By minimizing abu-
DOMESTIC VIOLENCE ISSUES
sive behavior, one is able to justify it and trivialize the victim’s injuries.
The most powerful reaction employed by batterers is denial. If there are no other wit-
nesses to an assault, this excuse can be used because the burden of proof is on the accuser.
The batterer can defend his position by attacking her position or credibility. If no other evi-
dence can be produced except her injuries, he can claim he doesn’t know what caused them
or accuse her of injuring herself. This is the most difficult defense mechanism to break
through, since it requires him to admit to something he completely denied before, conse-
quently acknowledging he lied.
Most men who are abusive to their intimate partners are not violent to others. Abusive
men are more likely to use controlling tactics against their partners where it might have the
least chance of legal consequences.
What makes a relationship with a history of violence so much different from one in
which disrespectful behaviors occur is the existence of fear for safety on the part of the vic-
tim. A physical assault often makes the other abusive behaviors much more threatening to
victims who live in fear of being physically harmed. A slammed door in a relationship with-
out fear for physical safety does not have the same impact it has in a relationship with a
history of violence.
Intervention strategies for batterers
In July of 1991, Iowa law was strengthened regarding how the criminal justice system
responds to domestic violence. One law mandates completion of a designated Batterer’s
Education Program (BEP) for defendants who are found or plead guilty to domestic assault.
Over 30 BEPs have been established in Iowa to service a primarily male population.
Except in rare cases, violent and abusive behavior is learned. This means it can be
unlearned. One goal of BEPs is to educate participants about the definition and identifica-
tion of abusive behavior, use of time outs, alternative respectful behavior and negative con-
sequences of abuse toward their partners, families and themselves.
BEPs follow standards of the Department of Corrections to maintain consistency,
accountability and to achieve accreditation. All BEPs use a group format with male/female
facilitator teams. The curriculum focuses on the participant’s use of violence as a tool to
gain power and control in a relationship. This structured group format is recommended
because of the abuser’s strong use of denial, blame and minimization. In order for partici-
pants to change, they first must admit their abusive behavior. The participant’s denial of
abusive behavior is often challenged by the group to help him become accountable for his
behavior.
Other intervention's
Conjoint therapy is not recommended for those in violent relationships. Although there
may be “couples’ issues” to work through, the violence is the perpetrator’s issue and must
be addressed first. There is a tendency in conjoint therapy to place responsibility on the
Rigid sex role
stereotypes are
pervasive as
abusive men
attempt to place
their partners in a
submissive role.
Iowa | Medicine
DOMESTIC VIOLENCE ISSUES
Batterers are
proficient at
“conning” the
physician by acting
the part of the
concerned,
solicitous husband.
dynamics of the relationship as the cause of violence. Often, abusive men are very willing
to enter conjoint therapy because the responsibility for their violence can be shared.
Physicians need to be wary of referring to counseling services which have strong beliefs
about traditional gender roles or which may encourage women to remain in a marriage at
any cost. This intervention may endanger women by not adequately assessing for safety or
by covertly supporting the abuse of power and control.
Individual counseling may be useful to abusive men and is often recommended for par-
ticipants while attending the BEP group. Individual counseling, however, does not provide
the structure and direction, nor does it allow for the valuable feedback a participant can
gain from other group members.
Physician response
When physicians are treating victims for injuries caused by abusive partners, the prima-
ry goal should be safety for the victim. When an abusive man accompanies his female part-
ner to the medical clinic or emergency room, he may show concern for her well-being and
may insist on staying close during the examination. Often, he will provide reasons (it was
“an accident” or “we were just messing around”) for her injuries. Batterers are proficient at
“conning” the physician by acting the part of the concerned, solicitous husband.
Physicians should trust their instincts in helping them determine the causes of the
patient’s injuries. It is a good idea to contact the local battered women’s shelter ahead of
time to learn what assistance is available for treating patients injured by their partners. If
abuse is suspected, physicians should treat and question the patient separately from her
partner in order to more accurately assess her safety. Important questions include: “Do you
feel afraid of your partner?” “What happens when you and your partner argue?”
Conclusion
Since 1990, 39 Iowa women have been killed by their current or ex-partners. They are
survived by 54 children. When children from a violent home grow up, they carry the tech-
niques they learned from their family of origin. Breaking this cycle of violence will require
a cooperative effort by professionals from many disciplines.
Iowa Programs for Abusive Men
Contact the Batterer’s Education Program representative in in the following cities for
locations of the 30 Iowa programs serving abusive men.
1. Waterloo
Bea Merritt
319/291-2091
5. Des Moines
Ken Smid
515/242-6924
2. Ames
Linda Murken
515/232-1511
6. Cedar Rapids
Jean Kuehl
319/398-3675
3. Sioux City
Jeff Page
712/252-0590
7. Davenport
Traci Bray
319/322-7986
4. Council Bluffs
Mike Hahn
712/325-0285
8. Ottumwa
Barb Macy
515/682-3069
HERE'S TO
THESE NURSES
WHO ARE
GOING THE
RURAL ROUTE
Congratulations to the winners of the 1994-95 Blue Cross and Blue Shield
of Iowa Foundation Rural Nursing Scholarships
MELANIE WYNJA
Sioux Center
Briar Cliff College
JUDI L. BYRNE MELINDA S. SCHAEFFER BEVERLY MENDENHALL
Platteville, WI Davenport Atlantic
Clarke College Coe College Drake University
JUSTINE WYMA JOANN REED KELLI FRANA WYNDIE CARY ANGELA M. SMITH
Sully Spirit Lake Ames Bloomfield Decorah
Drake University Graceland College Grand View College Iowa Wesleyan College Luther College
MELANIE D. HOLTON JENNIFER MOHN TERESA A. LANE
Cherokee Lansing Maquoketa
Morningside College Mount Mercy College University of Dubuque
JUDY VSETECKA
Lawler
University of Dubuque
Des Moines, Iowa
The Blue Cross and Blue Shield of Iowa Foundation is Sponsored by Blue Cross and Blue Shield of Iowa and is
a Licensee of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
Each of these scholarship winners has agreed to seek and continue employment in a rural Iowa community
following graduation. Scholarships totaling $44,000 are funded by the Blue Cross and Blue Shield of Iowa
Foundation and the eleven participating member colleges and universities of the Iowa College Foundation.
Congratulations to this bumper crop of future health care professionals!
Blue Cross and Blue Shield of Iowa
Foundation
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Iowa I Medicine
S C I E N C E AND EDUCATION
The Journal
of the Iowa Medical Society
A child’s perspective on abuse of a parent, by a parent
# Donner Dewdney, MD
Violence in our society has reached epidemic
proportions. Domestic violence between par-
ents is psychologically destructive to chil-
dren. Whether expressed physically or psy-
chologically, violence at home is frightening
to children. Frequently, violence and anger
are confused and it is important to differenti-
ate between the two. Parents should help
children understand that anger is a normal
and healthy human emotion that helps us
define our boundaries and set limits, that
people can be angry with each other without
resorting to violence.
Parents more prone to be victims or perpe-
trators of domestic abuse typically have prob-
lems with self-esteem. Parents with a low
self-esteem have trouble maintaining consis-
tent and healthy self concepts. They become
unpredictable with each other and their chil-
dren. A friendly teasing remark by a spouse
may be mistaken as a personal insult by the
aggrieved partner, who may lash out angrily
and violently.
A child’s perspective on anger
The appearance of violence and cruelty
changes the child’s perspective on anger. It
threatens the child’s sense of safety as well as
provokes fears in the child for the safety of
his parents. When physical violence occurs,
it results in a dramatic increase in the child’s
fears. Although physical abuse is characteris-
tically initiated by males, physical abuse by
wives of their hubands has increased over the
past 10 years.
A child who watches a parent being
injured frequently develops symptoms typical
of depression, i.e., crying spells and regres-
sive symptoms such as bed wetting, thumb
sucking and withdrawal. A child who witness-
es the abuse of a parent over the long term
frequently develops problems with loyalty,
initially aligning themselves with the abused
parent and later identifying with the abuser.
Sadly, such children may take the position
that daddy beat up mommy because “mom-
my deserves it.”
Over time, these children develop definite
personality changes, become preoccupied and
inattentive at school and may develop sec-
ondary behavioral problems. For many of
these children, the expression of anger in any
form becomes forbidden because of their fear
that it might explode into the rage and the
violence that the child has witnessed at home.
Begins as a defense strategy
A common side effect of chronic domestic
violence in the home is development of abu-
sive behavior by the child. This behavior may
begin as a defense strategy. The child cannot
wait passively each time to be a victim of vio-
lence but instead he tries to control the situa-
tion by becoming violent first. Often this
predatory behavior is directed towards small-
er, helpless siblings and playmates. This
defense strategy called “identification with
the aggressor” allows the victim to become
the perpetrator.1 An example of this could be
seen in the 1970s case of newspaper heiress
Patricia Hearst, where there was a transfor-
mation of Patricia Hearst the kidnap victim
to Patricia Hearst the bank robber.
Another side effect of domestic violence in
children is a problem with sleeping. Sleep
disorders are a frequent symptom of depres-
sion in these children and may also represent
the fact that most violent arguments break
out between their parents at night.
The treatment of children as victims of
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
January 1 995.
Donner Dewdney, MD
Dr. Dewdney is medical
director of Iowa Health
Systems, Department of
Psychiatry, Child and
Adolescent Services, in
Des Moines.
A child’s perspective on abuse of a parent, by a parent
continued
domestic violence and abuse is a lifelong
challenge. A key step in the foundation of
any treatment program is establishment of a
safe environment for the child. Although
temporary shelter care removes the immedi-
ate threat of physical danger, the children
continue to require reassurance and support
by caregivers that they will be safe. This is
true whether the children are returned home
or whether they are placed in residential
treatment.
Divorcing the abusive parent may not
bring relief to the child who often has to deal
with the additional trauma of a broken fami-
ly. Dr. Wallersteins’ research suggests that
70% of children whose families divorce
because of physical violence and abuse want-
ed their original parents to reunite when
interviewed by the research group five or 10
years after the breakup.- This strong wish
was expressed in spite of the obvious safer
and calmer environments in the children’s
new transitional homes.
Children feel responsible
Children need help understanding that
they are not the cause of their parents’ argu-
ments and beatings. Children feel responsible
and blame themselves for arguments which
may have focused on disagreements about
parenting and on the child’s behavior.
Children need to spend time with parents
and caretakers who love them and whose
behavior, not just words, establishes and con-
firms the promise of protection. Often chil-
dren who are victims of domestic abuse are
so traumatized that they require outpatient
therapy and, in some instances, referral for
long-term residential care.
These children struggle with explosive
tempers and a pervasive distrust of grownups
and authority figures. Treatment is focused
on providing a safe environment and develop-
ing rules and safeguards that teach them how
to manage their anger without resorting to
violence against others or harmful behavior
direeted toward themselves.
Finally, the recovery of these children is
dependent on the parents’ ability to change
their living patterns and resolve their prob-
lems with violence. There is a definite need
in our domestic courts to enforce severe
penalties for partner abuse with mandatory
sentencing and counseling when appropriate.
Our primary problem with violent behav-
ior by children is directly related to how our
children experience violence in the home —
not just in the streets. Our final responsibili-
ty to children is to reinforce appropriate and
safe parenting. 021
References
1. Anna Freud: Ego and the Mechanisms of Defense.
Madison, CT: International Universities Press, Inc. 1967.
2. Judith S. Wallerstein and Sandra Blakesley: Sec-
ond Chances: Men, Women & Children a Decade after
Divorce. New York. NY: Ticknor & Fields 1990.
SCIENCE AND EDUCATION
Understanding domestic violence
# Truce Ordoxa, MD
Because I am human, and I have accepted
that humanness, nothing human ever
shocks me — -for I am capable of everything
that is human.
Terrence, 400 BC, slave/philosopher
Setting the stage
If Shakespeare is correct in his assertion that
life is a stage, physicians must understand
the perceptional styles of every “player” in
the domestic violence drama in order to
understand it.
Domestic violence is defined as any voli-
tional (direct or indirect, verbal and/or non-
verbal) assaultive communication repertoire
aimed at establishing and reinforcing power
dominance over another person involved
with him or her in an intimate, sexual, theo-
retically peer relationship.
This all-encompassing definition subsumes
behavioral nuances wherein power can be
expressed even in subtle innuendoes of con-
trol. An example is directing slams or mani-
festoes at the driver of another car or a char-
acter on television, a newspaper or an absent
person which serve as “in-around” ways of
communicating power games to the signifcant
other. For instance, making joking or critical
comments which generalize all women.
Such “repertoires” are behavioral patterns
that have a particular set of features and
which are used consistently because of
assumed predictable responses from others.
Their sub-components are: 1) Motor-acts; 2)
emotional components — feelings and 3) cog-
nitive components — expectations and attri-
butions (what or who are perceived to be the
“triggers” for such repertoires).
Origins
The two fundamental types of aggression
involved in domestic violence are “hands on”
where there is actual violent touching or hit-
ting and “hands off” where the perpetrator has
no contact with the victim’s body. The vio-
lence is expressed through psychological bat-
tering and the destruction of pets or property.
Both types of aggression send the clear sig-
nal that the victim has no boundaries that
protect him or her from the other.
The three major determinants of aggression
are the origins of aggression, the instigators of
aggression and the maintaining conditions.
The origins of aggression are: 1 ) Biological
factors, 2) observational learning, 3) rein-
forced performance, 4) necessary instigator’s
presence and 5) presence of regulators of
such behavior.
In Central America, two Indian tribes dra-
matically present us with contrasting oppo-
sites in terms of aggression. The Tarahu-
mares have, for centuries, outlawed any
form of aggression by removing all violent
words from their language. Domestic vio-
lence, murder and child abuse are literally
nonexistent. The Yano-mamos, on the other
hand, glorify violence. Their language and
their handling of their women and children
are replete with violence. Yanomamo women
display the scars inflicted on them by their
men as badges of honor.
The Tasadavs in the Philippines have no
words for “hate,” “anger” and “cruelty.” For-
tune (1987) describes how the Tlingit people,
who are native to southeast Alaska, define wife
beating as a serious crime against the commu-
nity because all members of the community
are highly valued and necessary for tribal sur-
vival. In a rare case of wife beating, the whole
community came together for a potlatch. They
made the abuser’s clan make restitution to the
victim’s clan in material goods. Making such
Truce Ordoxa, MD
Dr. Ordona practices
adidt and child
psychiatry in Davenport.
Iowa 1 Medicine
SCIENCE AND E D I) CATION
Understanding domestic violence
continued
an act highly visible and expensive to the bat-
terer deterred future incidents.
Exonerative moral reasoning
There are seven common methods used by
batterers to neutralize self-condemnation of
their aggression:
• Justification of higher principles — “The
Bible says I am the head of my household.
My wife must submit.”
• Palliative comparison — “I am not a real
batterer because I never used a weapon.”
• Displacement of responsibility — “I was
too drunk, I didn’t know what I was doing.”
“She knows how to push my buttons.”
• Diffusion of responsibility — “It happens
in every marriage.”
• Dehumanizing the victims — “She de-
serves everything I dish out.”
• Attribution of blame to victims — “She
drove me to it.”
• Minimization and selective memory — “I
got mad at her only once.”
A person’s repeated use of violence de-
pends on: 1) appropriate inducements (insti-
gators of aggression); 2) functional value
(Does it serve a function? Does one get what
one wants by being violent?) and 3) reward
or absence of punishment.
The family, peers and the symbolic model-
ing of the media teach and exonerate vio-
lence in the following ways:
• Explicit demonstration of an aggressive
style of conflict resolution.
• A decrease in normal restraints over
aggressive behavior.
• Desensitization and habituation to vio-
lence.
• A shaping of expectations.
Instigators of aggression
There are three types of triggers of aggres-
sion: 1) Aversive instigators: to remove a per-
ceived obnoxious or irritating stimulus; 2)
incentive (inducement) instigators: to gain an
anticipated payoff and 3) delusional instiga-
tors: bizarre belief systems.
Aversive and incentive instigators activate
a variety of learned responses such as depen-
dency, achievement, withdrawal, psychoso-
matization, self-anesthetization with drugs or
alcohol, constructive problem solving or
aggression.
A person’s course of action depends partly
upon his acquired cognitive appraisal of the
event (specifically whether he thinks the
events can be controlled) and the model of
response he has learned to use with such
events. Sex role socialization contributes
here. O.J. Simpson was abandoned by his
father before he was born, raised in San
Francisco’s Potrero housing projects by an
absent mother in a violent, dyssocial environ-
ment and accorded celebrity status for
knocking people over in football. In addition,
there were no real consequences for thirteen
911 calls involving blatant spousal battering.
Maintaining conditions of aggression
The consequences (either rewards or pun-
ishments) determine whether aggression con-
tinues, becomes regulated or stops. There are
three types of rewards: 1) Tangible ones such
as establishing control in male-female relation-
ships, the expression of emotional arousal
(anger, anxiety, fear, frustration or sadness) or
getting what is wanted in a particular incident;
2) social status from acting in accordance with
sex role standards or from specific rewards
from peers and 3) alleviation of the perceived
aversive stimulus as the victim tries to accom-
modate the perpetrator to survive the abuse.
The rewards are most reinforcing if they
are characteristically unpredictable and
inconsistent.
External punishments as regulators are
effective only when the benefits derived from
the aggression are considered and the nature,
severity, timing and likelihood of the punish-
ment are appropriate.
Domestic violence is a community prob-
lem. This concept runs counter to the rabid
love affair we have with individualism in this
country. Unless we act as an interdisciplinary
team, we can never solve this problem. We
should attack this problem by aiming for
integration from design rather than falling
into eclecticism by default.
All approaches, regardless of name, should
first and foremost aim at safety for both the
victim and the perpetrator. For either of
them to be in rigor mortis would make all
intervention akin to securing the barn door
long after the mules have gone. DU
IowalMedicine
THE EDITOR COMMENTS
A world of violence
Our society faces a problem of monumen-
tal proportions — violence. Violence is
symptomatic of a deep social, political
and economic disease within our society. For
more than 100 years, we have understood that
the drive toward aggression is a basic compo-
nent of the human psyche. Children live in a
world of violent acts by adults. Adults promote
games of violence and present television pro-
grams that further expose children to violence.
It has been estimated that TV programs and
commercials show an act of violence or use a
spoken word of violence every 15 seconds.
Parents further accentuate this atmosphere at
sporting events by urging the youthful athletes
to “hit him; kill him.” A common expression of
desire for an object is “I would kill for one of
those!”
Data indicates that 90% of par-
ents hit toddlers; more than 50%
continue this practice into the teen-
age years. Violence is spoken, seen
and breathed . . . and seemingly
loved. Setting aside the numerous
forms of violence for the moment,
this issue of Iowa Medicine ad-
dresses the stigma of domestic violence. Stud-
ies show the knowledge level of physicians
concerning family violence and their skills con-
cerning intervention is varied and not well
defined.
About four million American women are
physically abused by their husbands or boy-
friends each year; domestic violence affects
one of four women. Domestic violence is esti-
mated to cost the United States $5-10 billion a
year in health care costs, lost productivity and
criminal justice intervention. Other statistics
are equally shocking. As many as 35% of
women who visit hospital emergency rooms are
seeking treatment for symptoms related to on-
going abuse, but only 5-10% of domestic violence
is recognized. IIovv many women seen in phy-
sician offices/clinics for “injuries” are recognized
as victims of violence is uncertain.
Recognition and reporting of child abuse has
improved because of the legal implications for
anyone knowledgeable of such; not so for vio-
lence against women. A prevailing question
concerning these battered women is “Why do
they tolerate abuse?” Is it fear of isolation, i.e.
no where to go in security or fear of retribution
from the batterer? Perhaps a bet-
ter question is “why does society
tolerate batterers?” The problem
has no boundaries; though pov-
erty accentuates the problem, we
see this social stigma among rich
and poor, urban and rural.
Many groups, notably the AMA,
have inaugurated programs to com-
bat domestic violence. Citizens must be made
aware of the prevalence of violence and become
involved. Physicians must recognize the vic-
tims and become involved. This is a social
problem and no person should be excused from
exercising social responsibility for those who
are abused. [Ml
Perhaps a
better question
is: “Why
does society
tolerate
batterers?”
Marion Alberts, MD
STATEWIDE
PHYSICIANS
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Iowa [Medicine
THE ART OF MEDICINE
Healing diversions
A hospital architect, with talent also as a
sculptor, once remarked that his atten-
tion to the colors and designs painted on
the walls, just as to many other environmental
details, served not only general utility, but
contributed to a “healing environment”. He
said he often has trouble persuading “hard-
headed skeptics” that the environment makes
any real difference to the task of getting well.
Those skeptics had not been adequately
schooled, he said, to understand that not all
things that count can be counted.
That conversation returned to me today
when, glancing through a profusely illustrated
history of medicine, I saw a splendid colored
photograph of the remarkably intact
amphitheatre neighboring the famous
Aesculapian Temple at Epidaurus,
Greece. There still stands the im-
pressive outdoor arena, adjacent
to the pavilion where the sick
sought soothing, healing sleep. This
edifice, seating 14,000, was a place
devoted to the drama, dance, song
or poetical recitations of the day.
There can be little doubt, from the
There can
be little
doubt such
entertainments
were deemed
therapeutic.
The pain of needles entering and gyrating in the
skin (acupuncture) or electrical shocks (TENS)
prompts the explanatory hypothesis of the “neu-
rological gatekeeper”. May we not watch a
video performance of Hamlet, ballet, a juggler
or Roseanne, listen to a strolling group of carol-
ers in the corridor, chat or play cards with a
visitor — and feel less of what misery ails us?
Are these not also gatekeepers?
Some of us may resist asserting that pleasing
colors, designs or art objects on the walls can be
similarly diverting or healing. Because we may
respond to the visual arts both cognitively and
emotionally, I wonder whether these complex
events deserve to be called right-brain or left,
but that datum isn't what matters most.
I cannot accept Norman Cousins’ well-publi-
cized claim that his watching and
laughing at Marx Brothers films each
day was indeed what healed — even
cured— -his alleged collagen vascu-
lar disease. Neither do 1 find reason
to reject what we know of biology,
pathophysiology or therapeutics in
order to grant the potential useful-
ness of entertainments and place-
architecture plus collateral evidence, that such bos of diverse types. Eventually we will learn to
entertainments were deemed therapeutic.
explain better the biochemical events that un-
That all but the most intense pain and suffer- derlie such clinical observations,
ing can be allayed through diversion and dis- Of course we should seek to cure when that
traction seems clear enough: have we not may be possible, but in all circumstances we
installed television in almost all hospital and must strive to make the patient feel better. That
nursing home rooms? Such stimulation, even was surely Aesculapius’ strong suit. My arehi-
if violent or melancholy, seems to block at least
temporarily the awareness of other distress.
tect friend is of that lineage and so, it seems, am
I. I hope you are, too. 023
Rich.\rd Gaplan, MD
Iowa [Medicine
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physicians to join them. Progressive town of
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addition to clinic building. Seven million
dollar addition remodeling of the hospital.
Moving costs, student loan repayment,
excellent salary, pension and benefits offered
with no building buy-in required. Contact
Fairfield Clinic, 304 South Maple Street,
Fairfield, Iowa 52556; 515/472-4141.
LeMarsy Iowa
Seeking quality physicians to prac-
tice at a 4300 average volume ER.
Director and staff positions. Full
and regular part-time. Democratic
group, highly competitive compen-
sation, paid St. Paul malpractice with
unlimited tail, excellentbenefitpack-
age/bonuses to full-time physicians.
ACUTE CARE , INC . , P.O. Box 515,
Ankeny, Iowa 50021; phone 800/
729-7813.
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Emergency Medicine, Council Bluffs, Iowa —
Opening available for qualified physician to
join group of emergency physicians. Training
and/or certification in primary care specialty
or emergency medicine. Flexible scheduling.
Newly remodeled emergency department.
Enjoy rural and urban atmosphere. Compen-
sation up to +$200K/year plus vacation. Write
Bluffs Emergency Care Services, PC, 933 East
Pierce Street, Council Bluffs, Iowa 51503; 712/
328-6111.
Emergency Medicine
Burlington, Iowa
Outstanding opportunity in emergency medi-
cine for primary care trained or experienced
emergency physician. Burlington Medical
Center is a 239-bed facility serving a multi-
county area in SE Iowa, NE Missouri and
western Illinois. 19,000 volume/double cov-
erage at peak times. BMC medical staff
consists of 80 physicians representing a broad
range of specialties. Burlington, a community
of 30,000, sits on the banks of the Mississippi
River with commanding river views giving
way to wide open horizons. Cultural opportu-
nities take many forms from art and history
museums to Mississippi River festivals and
SE Iowa Symphony Orchestra to the Iowa
state chili cook-off. Iowa’s reputation for
quality education is reflected in the Burlington
schools. Burlington is a community where
balance between family and career is easy to
maintain. Guaranteed minimum compensa-
tion package including paid malpractice. Send
CV or call Sheila Jorgensen, Emergency
Practice Associates, P.O. Box 1260, Wa-
terloo, Iowa 50704; 800/458-5003.
Family Practice, Carroll, Iowa — Outstanding
professional opportunity for family practice
physicians in a progressive, safe and clean
community of 10,000. These opportunities
are available for either experienced family
practice physicians, or the family practice
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more information, call Randy Simmons, Vice
President, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for S2.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is S20 per insertion. Display
classified advertising sells for S 25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa [Medicine
CLASSIFIED ADVERTISING
Sioux City — An excellent position is available
for a BC/BE family practice physician in a new
community health center. A full range of
family practice medicine is needed in a
community that is very supportive of the
center. Sioux City is a great place to raise a
family and has excellent public and parochial
school systems, a community college, 2 liberal
arts colleges, a graduate center, 2 excellent
medical centers, a Residency Training
Program (family practice), etc. The center
offers a competitive compensation and benefit
package, paid malpractice, etc. FEDERAL
LOAN REPAYMENT PROGRAM AVAILABLE.
For more information write Jeff Hackett,
Executive Director, Siouxland Community
Health Center, 1709 Pierce Street, Sioux City,
Iowa 51105 or call 712/252-2477.
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
General Faculty', Department of Family
Practice, University of Iowa College of
Medicine — The University of Iowa Department
of Family Practice offers full-time faculty
positions for residency-trained, ABFP certified
family physicians. Obstetric skills and
previous teaching experience highly desirable.
Additional faculty needed to address new
primary care initiatives. As a part of a full
academic department, responsibilities include
teaching, research and patient care. Well-
established, 24-resident program is university-
administered, community-based, and has
admissions at community and university
hospitals. A new model office facility is being
built. Well-established department with
special strengths in its clinical and behavioral
science faculty. As a “Big Ten” university
community, Iowa City is a great place to live.
Appointment and salary commensurate with
qualifications and experience. The University
of Iowa is an Equal Opportunity and Affirma-
tive Action employer. Women and minorities
are strongly encouraged to apply. Submit a
letter of interest and CV to Gerald J. Jogerst,
MD, Interim Department Head, Department of
Family Practice, 2149 Steindler Building, Iowa
City, Iowa 52242-1097; 319/335-8454.
Let Us Help You
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Primary Care Physicians and Subspecialists —
Are being sought for a variety of group
practices located throughout the upper
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For all of the facts, call 800/243-4353 or write
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PHYSICIANS
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Quality Recruiters
P.O. Box 1075
Fort Dodge, IA 50501
Phone 1-800-822-8567
Fax 1-515-573-3879
r“
Here’s to your Health
■ The Iowa Medical Society has published 4 patient inserts in
■ recent months on various topics: low back pain, vaccinations,
l menopause and estrogen therapy and prostate cancer. Original
inserts may be purchased for 15 cents each plus postage. A bill
■ will accompany your insert order.
I Call Jane Nieland or Bev Corron at 800/747-3070 or 223-1401
I to order inserts or send the completed form below to: Iowa
| Medicine, 1001 Grand Avenue, West Des Moines, LA 50265.
Name
| Address
■ City State Zip
J Insert ordered: Number of inserts J
Low back pain
Menopause/estrogen therapy
I Prostate cancer
| Vaccinations
I J
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J USAF HEALTH PROFESSIONS
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Iowa]Medicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrey, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljlto K. Zivkovich, MD
Robert A, Colnian, MD
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma , Allergy & Immunology’
Dermatology
Robert J. Barry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Bligard, MD, FAAD
James I). Bunker, MD, FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milner-Bragc, MD
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency’ Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gcrvich, MD
Daniel J. Schrocder, Ml)
Ravi K. Venturi, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Io>va Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul. MD, FICC
515/574-6840
Gastroenterology
Kenneth \V. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MD, ABIM
Grace Z. Aug, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MD
Laurence S. Krain, MI)
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgese, MD
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Ilosung (ill ung, MI)
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
PROFESSIONAL LISTING
Robert Havne, MD
Thomas A. Carlstrom, MD
David J. Roarin'. MD
1 1215 Pleasant, Suite 608
Des Moines 50309
515/283-5760
Neurological Surgery
Des Moines Neurosurgeons, PC
Robert C. Jones, MD
S. Randy Winston, MD
Douglas R. Roontz, MD
2600 Grand Avenue, Suite 210
Des Moines 50312; 515/283-2217
Chad D. Abcrnathey, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Wolfe Clinic, PC
Russell II. Watt, MD
John M. Graether, MD
Gilbert W. Harris, MD
Janies A. Davison, MD
Norman F. Woodlief, MI)
Erie W. Rligard, MD
David 1). Saggau, MI)
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
Neurological Surgery
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Obstetrics/Gynecology
Ophthalmology
Ophthalmic Associates, PC
Robert D. Whinery, Ml)
Stephen II. Wollten, MD
Robert B. Goffstein, MD
i Lyse S. Strnad, MD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MI)
Michael L. Long, MD
Bradley L. Isaak, MD
Randall S. Brcnton, Ml)
Janies L. Dummett, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., Ml)
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
General Ophthalmology
Orthopaedics
Iowa Orthopaedic Center, PC
Marvin II. Dubanskv, MD
Marshall Elapan, MD
Sinesio Misol, MI)
Joshua 1). Kimclman, DO
Timothy G. Kenney, MD
Lynn M. Lindaman, MD
Jeffrey M. Farber, MD
Kyle S. Gallcs, MD
Scott A. Meyer, MD
Cassim M. Igram, MI)
Donna J. Balds, MD
Jill R. Meilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MD
Marshall C. Greiman, MD
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Lakeview
Medical Park-West Des Moines
Wolfe Clinic, PC
Michael W. Hill, MD
Daniel J. Blum, MI)
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: S10.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neek Associates, PC
Kobcrt T. Brown, Ml>
Eugene Peterson, Ml)
Richard It. Merrick, MI)
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neek
Surgery, PC
Thomas .1. Itenda, Sr., MI)
James ", White, MD
Craig C. llertber, MD
Thomas J. Itenda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MI)
Guy E. McEarland, Ml)
Thomas F. Vincr, MD
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Sinks, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery’
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
Janies R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Perinatology
Des Moines Perinatal Center, PC
Neil T. Mandsagcr, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine arid Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MD
Donald L. Burrows, MI)
Michael Witte, DO
Gerard A. Matysik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary Diseases
Surgery
Wendell Donning, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice D. Schncll, MI)
Fareeduddin Ahmed, MD
Arthur B. Searlc, Ml)
Bogdan E. Krvsztofiak, Ml)
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, EACS
Dan P. Warliek, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Rehabilitation Medicine Associates
William I). dcGravcIlcs, Jr., MI)
Charles F. Dcnhart, MD
Marvin M. Ilurd, MD
William C. Koenig, Jr., MI)
Karen Kicnkcr, MD
Todd C. Troll, MI)
Lori A. Sapp, MD
Younkcr Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Rohcrt C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Advertising Index
Bernie Lowe & Associates 38
Blue Cross Blue Shield 6
BCBS Nursing Foundation 31
Dale Clark Prosthetics 32
IMGMA 47
IMS Services 18
Josephs 20
Medical Protective Company 8
Merrill Lynch 2
MMIC 48
Palisades Pharmaceuticals 20
Quality Recruiters 43
U.S. Air Force 43
Physician survey on domestic violence
Iowa Medical Society
This survey of Iowa physicians is part of a comprehensive project of the Iowa Medical Society’s Task Force on Domestic
Violence. The questions in this survey focus on domestic violence, which is defined as abuse between intimate part-
ners. The task force will use the results of the survey to determine future educational efforts for physicians. Many of these
questions have no right or wrong answers. Please fold your completed survey in half so the Iowa Medical Society’s return
address is on the outside, staple or tape it shut, affix a stamp and drop it in a mailbox. The deadline to return your sur-
vey is January 25. Thank you for your assistance.
Rebecca Wiese, MD
Chair, IMS Task Force on Domestic Violence
Name (optional)
1. What is your specialty?
2. What best describes your practice setting?
Medical practice/group Academic
Hospital Administration
3. Your age Gender: Male Female
4. Describe the frequency with which you treat victims of
domestic violence.
Frequently
Occasionally
Seldom
5. How capable do you feel of recognizing victims of
domestic violence?
Very capable
Somewhat capable
Not capable
6. How capable do you feel of intervening with victims of
domestic violence?
Very capable
Somewhat capable
Not capable
7. How comfortable do you feel asking patients if they
have been abused?
Very comfortable
Somewhat comfortable
Not comfortable
8. Have members of your office staff received education
regarding domestic violence?
Yes
No
9. How successful are you in getting patients to discuss
domestic violence?
Successful
Somewhat successful
Not successful
10. Do you have the information you need to recognize
and intervene in cases of domestic violence?
Have enough information
Gould use more information
Have no information
11. Would you distribute information to patients you sus-
pect are suffering from domestic violence?
Yes
No
12. You would be interested in receiving information on
which of the following aspects of abuse:
Physical indicators in patients
Behavioral indicators in patients
Characteristics of abusers
Legal obligations, ramifications
Liability issues
Intervention strategies
Referral options
Ethical issues
Other (please specify)
13. Are you aware of domestic violence resources and
services in your community?
Yes
No
14. If yes, do you refer patients to existing domestic vio-
lence agencies or services?
Yes
No
15. If no, would you like information on existing ser-
vices and referral resources?
Yes
No
16. If you intervene with a victim of domestic violence
and she returns home to her abuser, you have failed.
True
False
17. It is alright to call the police or social service agen-
cies without the victim’s consent.
True
False
18. Victims of domestic abuse should always be inter-
viewed alone.
True
False
19. Pregnant women are rarely battered.
True
False
20. Eventually, most women leave violent relationships.
True
False
21. If physicians treat the problem of alcohol or sub-
stance use and abuse, they will also be treating and pos-
sibly preventing domestic violence.
True
False
22. Victims of domestic abuse rarely seek treatment for
the signs and symptoms of abuse.
True
False
23. Couples’ counseling or family intervention is con-
traindicated for domestic violence situations.
True
False
24. All women who are depressed or who have attempt-
ed suicide should be screened for domestic abuse.
True
False
25. Women who abuse drugs or alcohol are more likely to
be victims of domestic violence.
True
False
26. Physicians should not document abuse in the
patient’s chart unless the patient confirms abuse has
occurred.
True
False
27. If a woman misses or cancels an appointment, she
should be screened for domestic abuse.
True
False
28. When screening for domestic abuse, it is better to ask
specific rather than open-ended questions.
True
False
29. Nonspecific physical complaints such as GI upset,
insomnia, nightmares or anxiety can be indicators of
domestic abuse.
True
False
30. More often than not, domestic abuse victims will
deny they are being abused.
True
False
31. Which of the following are clinical signs of possible
domestic abuse? (Check as many as apply)
Recurrent STDs
Migraines
Anxiety during pregnancy
Casual response to serious injury
Anorexia or bulimia
Facial lacerations
Non-specific pain
Palpitations or dizziness
Domestic abuse scenarios
Please read the following scenarios and then choose the course(s) of action you would take.
Scenario 1 (Submitted by J.W. Ankeny, DO, Des Moines)
A single, 25 year-old nurse at a metropolitan hospital presents to her family physician’s office
on multiple occasions for vaginal discharge. Repeated physical examinations and laboratory
workups provide no diagnosis. Non-specific treatments for vaginal infections provide no relief to the
patient. The patient presents yet again for the same complaint. The physician should:
(1) Reevaluate the patient physically and through laboratory tests.
(2) Refer her to an OB/Gyn specialist
(3) Question the patient about her social history including sexual preference, dating history,
family and living situation, method of contraception, etc.
(4) Review the screening protocols for domestic abuse with the patient.
According to Dr. Ankeny, this real life patient was questioned (3) about her living situation and
was found to be cohabitating with a policeman. He was physically abusing her with the tools of his
trade. Upon this revelation, the patient was referred for counseling and a positive outcome ensued.
Scenario 2 (Submitted by Robert McAfee, MD, president of the American Medical Association)
An older, middle-aged woman, the wife of a respected businessman in a small city, presents in
the office of a surgeon complaining of breast pain. She has a family history of breast cancer. The
physician examines her and orders a mammography, the results of which are normal. The physi-
cian relates the mammography results to the patient, reassuring her that everything is fine. He asks
her to visit him again in six months. However, less than three months later she returns, again com-
plaining of breast pain. The physician should:
(1) Conduct another physical examination.
(2) Do another mammography.
(3) Refer her to a specialist.
(4) Consider the screening protocols for domestic abuse.
(5) Search the literature for articles on breast pain.
According to Dr. McAfee, during the woman’s third visit, he reexamined her (1) and noticed
bruises on her chest. She was actually a victim of long-term abuse by her husband. He intervened
and referred the woman’s husband to appropriate counseling which proved successful.
FOLD IN HALF
Place
Stamp
Here
Iowa Medical Society
1001 Grand Avenue
West Des Moines, IA 50265
Iowa iMedicine
THE PRESIDENT COMMENTS
The AMA in action
Sitting in on the AMA interim meeting is an
emotional roller coaster. Sometimes you
can actually feel the train building up
steam, rolling over the opposition toward the
final vote. At times, it appears arguments are
rehearsed with speakers rising from different
areas of the hall to make their case. Such
arguments have a good chance of being ac-
cepted. Knowledge of the issues, timeliness and
personal association all make an impact. Reso-
lutions upon which the delegates agree become
the policy your AMA staff pursues.
The AMA is involved in a wide range of issues
which affect the way we practice medicine, our
medical school and post graduate education,
the regulations under which we work and the
way we are paid. The governmental bureau-
cracy gets information and recom-
mendations from many constitu-
ents. These recommendations are
not beneficial for physicians or
their patients. This impresses upon
us the need for a united physician
organization working for positive
influences on our patient’s health.
My assignment was reference
committee “E” chaired by a fellow North Cen-
tral Medical Conference member, Richard
Tompkins, a rheumatologist from Mayo Clinic.
A resolution that may affect your journal read-
ing dealt with sexually exploitative advertising
to physicians. The women’s section and stu-
dent section didn’t think it proper that medical
products and technology ads should feature
exposed female parts in various poses. The
House of Delegates approved their resolution.
Another resolution concerning female geni-
tal mutilation sparked a lengthy discussion. Its
history, cultural background and countries
where practiced entered the informative dis-
cussion. In the end, a resolution was approved
calling for counseling against the practice.
Managed care took center stage at this meet-
ing. The Board of Trustees presented a 57-page
report describing current trends, risks and op-
portunities for patients and physicians. A de-
tailed AMA strategy for managed care and the
private sector was presented. You can get a
copy of “Managed Care and the Market”, a
summary of national trends affecting physi-
cians, from your state or national organization.
The House of Delegates approved the report
and emphasized four principles:
1. Professionalism (medical
science and ethics)
2. Patient and physician au-
tonomy
3. Patient and physician rights
4. Practical assistance to phy-
sicians
Health system reform, employer
control of health insurance choices, AMA bud-
get, antibiotic usage and bacterial resistance
and control of E. coli infection were other
issues your House of Delegates acted upon.
I came away with the realization that the
AMA and many of your fellow physicians are
working to keep American medicine the best in
the world for all of us. 013
Managed
care took
center stage
at the
AMA interim
meeting.
James White, MI)
Iowa Medicine Volume 85 / 2 Febmary 1995 55
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-562-2218
Des Moines: 515-245-4688
_
Iowa [Medicine
GUEST EDITORIAL
North Iowa responds
to domestic violence
Improving the health status of Iowans
through an integrated system of hospitals,
physicians and other quality health care
services is the vision of North Iowa Mercy
Health Center located in Mason City, Iowa.
In response to this charge, the NIMHC
Women’s Health Center is developing a com-
munity approach to domestic violence as part
of the Center’s quality improvement process.
Working with the Crisis Intervention Center
and members of the North Iowa Batters Educa-
tion Task Force, professional education regard-
ing identification and intervention with survi-
vors of domestic abuse was selected as our
community’s greatest need in the area of do-
mestic violence.
The hospital’s Regional Health Education
Center has assisted us in providing
a continuing education program
targeting nurses, social workers
and physicians and has purchased
a professional educational video
series entitled “More Than Just
Words: Responding to Domestic
Violence”. This program, in con-
junction with educational materi-
als developed by the Iowa Medical Society, will
be utilized to increase skills of all health profes-
sionals within the north Iowa network of Mercy
hospitals and physician clinics.
Since studies show that 25% to 35% of women
who visit emergency departments are there for
symptoms related to ongoing domestic abuse,
NIMHC Emergency Center personnel are par-
ticipating in the initial inservice training.
In addition, the Women’s Center is part of a
hospital task force to enhance existing proce-
dures and to develop screening criteria which
will be applicable to all health care providers
(including physician clinics) in the North Iowa
Mercy System.
The Cerro Gordo County Medical Alliance
has offered to assist in the support and dissemi-
nation of information throughout northern
Iowa. Posters with resource information devel-
oped in cooperation with the IMS will be placed
in public places such as women’s restrooms
where they will be readily and safely available.
Goals for the future include the development
of an ongoing multidisciplinary task force to
identify, develop and monitor services to survi-
vors of domestic violence, enhance health care
providers’ use of advocates and
assist in supporting existing ser-
vices.
A task force of the Iowa Su-
preme Court, the AMA, JCAHO
and other experts in the field of
domestic violence agree that phy-
sicians and community hospitals
serve a key role in addressing and
preventing domestic violence. Together we
have an opportunity and obligation to improve
the quality of life for these survivors and their
families. We at North Iowa Mercy Health Center
have gladly accepted the challenge to provide
leadership in addressing domestic violence to
improve the health of the community in which
we live. Cu]
The Women’s
Health Center
is developing a
community ap-
proach to domes-
tic violence.
Maxixe Brixkmax
Ms. Brinkman is director
of the Women ’s Health
Center in Mason City,
Iowa and an IMS
Alliance member. The
Women’s Health Center, a
service of North Iowa
Mercy Health Center,
provides a multi-
disciplinary approach to
primary health care.
Iowa Medicine Volume 85 / 2 Februan’ 1995 57
Iowa | Medicine
IMS Update
AT A GLANCE
According to a recent
issue of JAMA, nearly
44% of college students
are binge drinkers and
nearly 20% binge drink
on a regular basis.
Colleges in the North-
east and North Central
regions of the U.S. had
higher rates of binge
drinking than those in
the West or South.
As of press time,
President Clinton was
continuing the search
for a replacement for
U.S. Surgeon General
Joycelyn Elders, who
was fired for comments
made during an appear-
ance at the United
Nations. While the presi-
dent denied Dr. Elders
was fired for political
reasons, AM News spec-
ulated the president is
“actively positioning
himself as a moderate
Democrat and can no
longer afford to be
undermined by his own
surgeon general”.
IMS represented at AMA interim meeting
Iowa delegates were among 413 physicians
participating in the December AMA Interim
Meeting, a meeting dominated by discussion
of managed care issues.
The AMA Board of Trustees presented a
57-page report describing current trends in
managed care, summarizing risks and oppor-
tunities for physicians and patients and pre-
senting detailed AMA strategy for managed
care and the private sector.
The report emphasizes four principles —
professionalism, patient and physician auton-
omy, patient and physician rights and practi-
cal assistance to physicians.
The House adopted a substitute resolution
calling on the AMA to undertake or continue
these activities:
•Support at the federal and state level for
the Patient Protection Act.
•Publicize cost factors which contribute to
escalation of health care costs, including
patient responsibility and administration.
•Support state and county efforts on
behalf of member physicians deselected by
managed care plans for other than quality
reasons.
•Investigate and publicize the ways man-
aged care can be involved in education, train-
ing and research.
•Evaluate the impact of managed care
plans or medical care quality and medical
ethics and identify practices that adversely
affect delivery of quality health care.
The AMA House also reordered the AMA’s
health system reform priorities, placing more
emphasis on regulation of managed care
plans and less on universal coverage.
According to AM News, the move “reflects
political realities under the new Republican-
controlled Congress”
The AMA’s top reform priorities are: leg-
islative protection of physician and patient
autonomy under managed care, curbs on
malpractice suits, insurance reform limiting
carriers’ risk-selection practices, antitrust
relief, more freedom for physicians to take
collective action and creation of tax-sheltered
medical savings accounts.
The AMA is also prepared to do battle with
Republicans on further reductions in
Medicare and Medicaid reimbursement to
providers.
In other matters, a resolution introduced
by the Iowa delegation through the North
Central Medical Conference calling for a
study of reimbursement for telemedicine pro-
cedures was approved by the AMA House.
Also, considerable concern was expressed
at a reference committee hearing regarding
presentation of smokers’ rights articles in
Weekly Reader without accompanying infor-
mation on the adverse effects of tobacco use.
Final dues notice will be sent this month
The fourth and final IMS/AMA dues notice
will be sent to IMS members in mid-February.
Dues are considered delinquent on March 1.
Prompt payment of dues will be appreciated.
Specialty Society Update
The second Management Education Program (MEP)
begins March 24. This physician and manager leader-
ship program is designed for graduate level students.
Call Dana Petrowsky, 800/728-5398, for more infor-
mation.
The Iowa Psychiatric Society Spring Meeting will be
April 7 at the Des Moines Marriott.
Dr. Roy Overton, president of the American Medical
Directors Association, Iowa Chapter, will represent
Iowa at the White House Conference on Aging this
spring in Washington, DC.
There will be an Iowa Chapter Night reception at the
American College of Cardiology annual meeting at the
New Orleans Hilton March 20.
The Iowa Association of County Medical Examiners will
meet Friday, February 17 at 2 p.m. at IMS headquar-
ters.
58 Iowa Medicine Volume 85 / 2 February 1995
CURRENT ISSUES
Domestic abuse topic at Scientific Session
A panel discussion of domestic abuse will
culminate the 1995 IMS Scientific Session
April 28-30 at the Marriott Hotel in Des
Moines. The Scientific Session will be held in
conjunction with the 1995 House of
Delegates meeting.
Participating in the panel discussion will
be an attorney, a police officer, an emergency
room physician, advocates for battered
women and Dr. Lonnie Bristow, president-
elect of the American Medical Association.
The 1995 Scientific Session will begin
Friday, April 28. Topics include diabetic
retinopathy, asthma deaths, the tube and ton-
sil controversy and a special presentation on
Iowa’s trauma plan and the United Airlines
crash in Sioux City.
Watch the March Iowa Medicine for a
detailed Scientific Session program and regis-
tration information. You are encouraged to
reserve your hotel room in advance by calling
the Marriott at 800/228-9290.
Award nominees sought
IMS is seeking nominees for its Physician
Award for Community Service and for the
Outstanding Iowa Medical Office Admin-
istrator Award. These awards will be present-
ed during the 1995 House of Delegates.
Anyone can nominate a physician for the
Community Service award by writing to Tina
Preftakes at the IMS, 1001 Grand, West Des
Moines, IA 50265. The deadline is March 1 .
To nominate someone for the clinic man-
ager award, call Dana Petrowsky at IMS
Services, 515/223-2816 or 800/728-5398 by
February 15.
IMS election process continues
Delegates to the 1995 IMS Nominating
Committee are being chosen at district cau-
cuses around Iowa. The Nominating
Committee will meet March 12 by telephone
to assemble the candidate slate for the 1995
elections. The election will take place
Sunday, April 30 during the IMS House of
Delegates meeting.
Offices to be filled include: president-elect,
vice president, trustee, House of Delegates
speaker and vice-speaker, one AMA delegate
and one AMA alternate.
Focus on IMS Alliance
The IMS Alliance is committed to the concept of “Zero
Tolerance for Violence”. Initiatives across the state
include:
•Karen Johns, Cedar Rapids, coordinates distribution
of “Careline” crisis cards to all junior high and high
schools in Iowa.
•Cindy Ehrecke, Davenport, distributes “I Can
Choose” coloring books to grade school students.
•Karen Messamer, Oskaloosa, promotes “Baby Think
it Over” dolls for teen pregnancy prevention.
•Adrianne Lugo and Teri Garrett, Iowa City, organized
fund-raiser for local domestic violence center.
•Marcia Heggan, Marshalltown, supporter of
Domestic Violence Alternatives and Sexual Assault
Center.
•Bonnie Zittergruen, Des Moines, member of Iowa
Coalition on School Health.
•Carrie Hall, Des Moines; Laurie Stevens, Ankeny;
Mary Conway, Emmetsburg — members of the IMSA
Spouses Offering Support Committee.
•Marta Abele, Dubuque, active supporter of Battered
Women’s Program.
Contributed by Barbara Bell, president, IMSA.
Special guests at IMS Annual Meeting
Dr. Lonnie Bristow, an internist from San
Pablo, California, will be a special guest at the
IMS House of Delegates April 28-30 at the
Marriott Hotel in Des Moines. Dr. Bristow will
address the IMS House of Delegates on
Saturday, April 29 and will take part in a
Sunday morning panel discussion on domes-
tic violence. Dr. Bristow has been a member
of the AMA Board of Trustees since 1985.
Dave Werner, a political satirist and former
member of the Capitol Steps will entertain at
the IMS Annual Banquet Saturday evening. A
graduate of Yale Law School and former
member of a Washington, DC law firm,
Werner has been featured on the CBS
Evening News and the Today Show. He is a
native of Manchester, Iowa, d
Dave Werner
Dr. Bristow
Iowa Medicine Volume 85 / 2 February 1995 59
Iowa [Medicine
Futures
AT A GLANCE
Watch the March Iowa
Medicine/or a reprint of
Dr. Robert McAfee’s pre-
sidential report to the
AMA House of Delegates
at the December interim
meeting. The entertain-
ing presentation is enti-
tled “King Will and the
Fold Humours: A Fable
for Reform’’.
•
In January , the IMS
Board of Trustees met
with officials of Blue
Cross/Blue Shield to dis-
cuss the future of pri-
vate health reform in
Iowa. Blue Gross and
Blue Shield remains the
largest third party car-
rier in the state.
Futures issues in March Iowa Medicine
Iowa physicians are faced with a myriad of
options for changing their practice situations,
and many are wondering what direction to
take.
In the March Iowct Medicine, a feature
article by an expert discusses pitfalls physi-
cians could encounter when altering their
practice situation — whether it be a merger,
sale or other move toward managed care.
In the May magazine, a senior financial
consultant with a Washington, DC firm will
discuss financing of physician-driven man-
aged care ventures.
Medicare Conversion Factors good news
The 1995 Medicare conversion factors
(CF) have resulted in the biggest Medicare
reimbursement increase for physicians in
years. The CFs published in the December 8,
1994 Federal Register are $36.38 (a 7.9%
increase) for primary care services, $39.45 (a
12.2% increase) for surgical care procedures
and $34.62 (a 5.2% increase) for other non-
surgical services and procedures.
The CF is used by HCFA to determine the
new Medicare fee schedule for services on
and after January 1, 1995. Payment is calcu-
lated by multiplying the relative value of a
service or procedure by the CF and adjusting
for local practice costs. (See next article.)
The CFs are based on a formula that
includes physician performance in the nation
compared to set targets (the Medicare
Volume Performance Standards). If the vol-
ume of physician services is above the target,
the reimbursement rate is lowered. If the vol-
ume is below the target, the rate is increased.
The 1995 increase is a reward for physician
performance in 1993.
Although the big increase has been criti-
cized by economists and others, experts
point out that this increase will help close the
gap between Medicare payments and private
sector payments. Medicare payments cur-
rently are only 59% of private payments.
Physician payment accounts for about 23% of
total Medicare spending.
The 1995 reimbursement increases are
substantially above the inflation rate (2.6%)
and consumer price index for medical care
cost increases (4.7%). Physicians should not
expect similar reimbursement increases
every year. HCFA has tightened the Medicare
Volume Performance Standards for 1995 — a
13.8% increase in the volume of primary care
services, 9.2% for surgical care and 4.4% for
nonsurgical care. The reimbursement rate for
1997 will be based on physician performance
compared to these targets.
Iowa GPCIs decrease
The Geographic Practice Cost Indices
(GPCIs) for Iowa have decreased. The
decrease will be phased in over the next two
years.
The GPCIs are used by IICFA to adjust for
local practice costs when calculating the
Medicare fee schedule. OBRA ’89 requires
that the GPCIs be reviewed and revised if
necessary at least every three years. The new
GPCIs are based on data from 1990-92.
The GPCI calculation has been widely crit-
icized; however, HCFA stated that the data
used are the best sources available. IICFA has
announced a study to establish an alternate
method for establishing practice expenses,
one component of the GPCI. A new method-
ology would not be implemented until
January 1, 1998.
Iowa’s GPCIs in 1995 will be .968 (work),
.898 (practice expense) and .672 (malprac-
tice). In 1996, they will be .960 (work), .877
(practice expense) and .679 (malpractice).
This is a decrease of -1.9% in Iowa.
Changes throughout the country ranged from
a nearly 8% increase in Rhode Island to a -6
to -8% decrease in Illinois.
For more information on the Iowa GPCIs,
call Barb Heck at the IMS, 800/747-3070.
CURRENT ISSUES
HMOs ‘awash in cash’
According to a recent article in the Wall
Street Journal, IIMOs arc “so awash in cash
they don’t know what to do with it all”.
During the past year, liquid assets of many
HMOs have climbed 15% or more.
Four of the industry’s biggest companies
have tucked away more than $1 billion and
some midsize IIMOs are sitting on $500 mil-
lion each. Thanks to rapid membership
growth and slowing medical costs, many
HMOs are pulling in money faster than they
can spend it.
Dr. James Todd of the AMA was quoted
recently as saying the AMA “has some real
problems with the for-profit mentality of
some health plans.”
AMA: Financing reform essential
TO PRESERVE MEDICARE PROGRAM
Below are excerpts of a response by AMA President
Dr. Robert McAfee to the entitlement commission
report issued by Senators Kerrey and Danforth:
“Despite concerns with some policy options,
the AMA believes the Bipartisan Commission on
Entitlements and Tax Reform report creates the
context for a much needed national debate on
the future financial health of the Medicare pro-
gram. Medicare is at a crossroads. Without com-
prehensive restructuring, Medicare is headed for
a fiscal train wreck early in the next century.
“The AMA has significant concerns about
proposals to cut reimbursement. This short-
sighted approach avoids the underlying prob-
lems, exacerbates private sector cost shifting
and limits access to care for the neediest
Medicare patients.
“Increases in medical costs have moderated.
Recently, the government reported that private
sector health care spending increased at its low-
est rate in a decade with physician services
making the smallest increase — 5.9% — of any
sector. According to the Physician Payment
Review Commission, physician payments under
Medicare in 1993 increased at one-half of the
consumer price index inflation rate and sub-
stantially below all other Medicare categories.
“A careful examination of the facts must pre-
cede hasty imposition of politically expedient,
short-term budget cuts that cover up the prob-
lem and endanger the future care of the elderly
and disabled. Arbitrary spending slashes and
provider payment rate cuts are not solutions
and will be vigorously opposed by the AMA.”
IMS II VS CASSETTES ON MANAGED CARE ISSIES
If you missed the Iowa Medical Society’s
“Organizing for Change” conference, you can
order a set of cassette tapes containing the
entire program, including an entertaining pre-
sentation on the Washington scene from Dr.
James Todd of the AMA. Here’s what Iowa physi-
cians said about the conference speakers:
“A high quality program — keep them
coming. ”
“Plenty of useful practical advice.”
“I wish all Iowa physicians could
hear this program. ”
The set of cassette tapes and related materials
is $42; the cassette tapes alone are $26.25. To
order, call Linda Tideback at the IMS, 800/747-
3070.
Getting them to want you
In the January, 1995 California Physician,
an attorney offered the following ten tips on
how to get a managed care plan to want you:
1. Promote your practice not only to health
plans, but also to potential patients and col-
leagues.
2. Retain existing patients because a large
patient base improves your chances of being
accepted by a plan.
3. If you are a specialist, get to know the
plan’s primary care physicians and what they
expect from specialists.
4. Ask your patients to advocate for your
participation.
5. Mingle with business groups.
6. “Court” the plan by taking someone
from the plan out to lunch. Learn as much as
you can about the plan from the administra-
tor or medical director.
7. Computerize so you can generate
encounter and outcomes data quickly.
8. Compare yourselves using UR data (no
names) to learn how to perform better.
9. Run your office efficiently by cross-
training employees.
10. Make sure your credentials are up to
par. DS]
Iowa Medicine Volume 85 / 2 February 1995 61
Iowa [Medicine
Legislative Affairs
AT A GLANCE
The IMS lias position
papers outlining IMS
policy on a number of
key issues including
any willing provider,
managed care, liability
reform and tobacco
issues. For copies, call
Lyn Durante at the IMS,
515/223-1401 or toll-free
800/747-3070.
•
According to a recent
Des Moines Register
article, the legislature
and governor are “ tired
of waiting for the federal
government to do some-
thing about health care
problems ” so are mov-
ing ahead with their
own agenda. The agen-
da will include a pro-
posal to limit non-eco-
nomic damages and the
statute of limitations in
m ed ica l malpractice
cases. Insurance reform
proposals including
elimination of pre-exist-
ing conditions are also
anticipated.
IMS cosponsors telemedicine conference
The Iowa Medical Society was a cosponsor
of the largest videoconference ever held on
Iowa’s fiber optics network Monday evening,
January 9. There were nearly 1,000 confer-
ence registrants at 59 sites around Iowa.
Three expert panels discussed key issues
raised by telemedicine technology, including
reimbursement, liability, confidentiality and
physician licensure.
Several IMS member physicians participat-
ed on the panels. There was also a demon-
stration of a cardiology consult between a Des
Moines physician and a physician in
Jefferson. Though Iowa has become a world-
wide leader in this technology, everyone
agreed that, at this point, no one has answers
for the many questions raised by telemedi-
cine technology. Among key issues discussed
during the conference were:
•How will rural hospitals be able to afford
the equipment to use telemedicine? (There
was general consensus that unless rural hos-
pitals receive financial assistance, telemedi-
cine technology will not be feasible for them.)
•When will IICFA decide to reimburse for
telemedicine services to Medicare patients?
(A HCFA representative said that agency
needs “more clinical data” which proves
telemedicine is safe and effective.)
•How will the move toward capitation
affect reimbursement for telemedicine?
•Will third party payers be willing to pay
for the increased access to specialists made
possible by telemedicine?
•Who is liable if the quality of a transmis-
sion is poor?
•Will physicians consulting from out-of-
state offices need Iowa licenses? Who is being
electronically transported?
•How will patient confidentiality be pro-
tected?
IMS has available a videotape of the con-
ference and a report from the Iowa
Telemedicine Advisory Council. Call Becky
Roorda at the IMS, 800/747-3070.
Contacting York Legislators
Telephone number during the session:
Senators 515/281-3371
Representatives 515/281-3221
Governor 515/281-5211
Write to them at:
STATEH0USE
Des Moines, Iowa 50319
You may also contact your legislators at home
when the legislature is not in session. If you don’t
know who your legislator is or need your legisla-
tor’s home address and phone number, call Lyn
Durante of the IMS staff, 800/747-3070 or
515/223-1401.
Iowa Senate, House committee chairs
Following are chairs of committees which deal
with health care issues in the Iowa Legislature:
SENATE
Human Resources
Judiciary
State Government
Commerce
Communications
Appropriations
Budget Subcommittees
Human Resources
Human Services
Sen. Elaine Szymoniak
Sen. Randal Gianetto
Sen. Michael Gronstal
Sen. Patrick Deluhery
Sen. Robert Dvorsky
Sen. Larry Murphy
Sen. Tom Flynn
Sen. Johnie Hammond
HOUSE
Appropriations
Commerce/Regulations
Human Resources
Judiciary
State Government
Technology
Budget Subcommittees
Health Human Rights
Human Services
Rep. David Millage
Rep. Janet Metcalf
Rep. Horace Daggett
Rep. Charles Hurley
Rep. Mona Martin
Rep. Bob Brunkhorst
Rep. Joseph Kremer
Rep. Hubert Houser
IMS “Medicine Day” at Iowa legislature
Wednesday, March 22 will be ‘Medicine
Day’ at the Iowa Legislature — a day for Iowa
physicians, physician spouses and clinic
62 Iowa Medicine Volume 85 / 2 February 7995
CURRENT ISSUES
managers to see first-hand how the legislative
process works.
Medicine Day is open to any IMS member.
The day will include luncheon at IMS head-
quarters and an afternoon at the statehouse
talking to legislators, attending committee
meetings and listening to debate.
To register or for more information, call
Paul Bishop or Lyn Durante at the IMS,
515/223-1401 or 800/747-3070. Registration
deadline is March 10.
I Free substance abuse directory available
The IMS Committee on Maternal and Child
Health and the Maternal Mortality Committee
urge all physicians to screen patients — espe-
cially pregnant women — for possible sub-
stance abuse. Treatment may include referral
to a state-funded agency.
To get a free directory of all state substance
abuse programs, contact the Iowa Substance
Abuse Information Center, 800/247-0614.
The Center is required to provide services
to pregnant women with alcohol or other sub-
stance abuse problems. Services are offered
free or on a sliding fee scale.
Any willing provider
The “any willing provider” issue is expect-
ed to be discussed during the 1995 legislative
session. The IMS is part of a coalition oppos-
ing legislation requiring managed care plans
to include any provider who agrees to the
terms and conditions of the plan.
In 1994, legislation was passed by the
Senate to require such plans to provide
direct access to services of a long list of
providers. The bill died in the House. The
IMS opposes this mandate because:
1) It will prevent effective management of
care; 2) It will significantly increase the cost
of health care coverage; 3) Increased costs
may result in fewer employers providing
health benefits; 4) State legislation affects
only about 25% of the insurance market; 4)
Employers may decide to self-insure since
federal ERISA regulations do not contain
such mandates.
IMS members are encouraged to ask legis-
lators to oppose such mandates. The IMS is
negotiating directly with third party payers
to ensure physicians and patients are treated
fairly by managed care plans. DID
Iowa Congressional Delegation and District Offices
U.S. Representatives
District 1
Jim Leach (R)
21S6 Rayburn House Office Bldg.
Washington, DC 20515
202/225-3806
Davenport headquarters:
319//326-1841
District 5
Tom Latham
516 Cannon House Office Bldg.
Washington, DC 20515
202/225-5476
Sioux City:
Spencer:
Orange City:
Fort Dodge:
712/277-2114
712/262-6480
712/737-8708
515/573-2738
District 2
Jim Nussle (R)
303 Cannon House Office Bldg.
Washington, DC 20515
202/225-2911
Dubuque headquarters:
319/557-7740
District 3
Jim Lightfoot (R)
2161 Rayburn House Office Bldg.
Washington, DC 20515
202/225-3806 fax — 202/225-6973
Iowa WATS: 800/432-1984
District 4
Greg Ganske (R)
1108 Longworth House Office Bldg.
Washington, DC 20515
202/225-4426 fax — 202/225-3193
Des Moines headquarters:
515/284-4634
U.S. Senators
Charles Grassley (R)
135 Hart Senate Office Bldg.
Washington, DC
202/224-3744
20510
Des Moines:
515/284-4890
Sioux City:
712/233-1860
Waterloo:
319/232-6657
Cedar Rapids:
319/363-6832
Davenport:
319/322-4331
Tom Harkin (D)
531 Hart Senate Office Bldg.
Washington, DC
202/224-3254
20510
Des Moines:
515/284-4574
Cedar Rapids:
319/393-6374
Davenport:
319/322-1338
Council Bluffs:
712/325-0036
Sioux City:
712/252-1550
Dubuque:
319/582-2130
Iowa Medicine Volume 85 / 2 February' 1995 63
Iowa [Medicine^
Medical Economics
AT A GLANCE
The California Medical
Association Board of
Trustees authorized
CMA to file a lawsuit in
US District Court to stop
implementation of Prop.
187’s health care provi-
sions. The lawsuit says
Prop. 187 is unconstitu-
tional and threatens all
residents of California
with “epidemics of enor-
mous proportions". Prop.
187, says CMA, would
breach physicians’ pro-
fessional ethics and
place physicians who
accept public funds in
legal jeopardy.
•
President Clinton has
vetoed federal funding
for research on embryos
created solely for
research purposes, but
did not rule out use of
federal funds for
research on leftover
embryos created as part
of fertilization treat-
ments at in vitro fertil-
ization clinics.
More legal action in mental health contract
It looks as though implementation of a
managed care plan for mental health services
to Iowa Medicaid patients has hit another
major legal snag.
Value Behavioral Health (VBH) has taken
another legal step to defend its original win of
the Iowa State Medicaid mental health con-
tract.
In June, 1994, the state announced it had
chosen VBH from among eight bidders for the
mental health managed care contract.
However, Medco, a California firm which was
runner-up in the bidding, filed a lawsuit alleg-
ing a flawed selection process.
A Polk County judge later ruled in favor of
Medco, citing “overwhelming circumstantial
evidence of impropriety”. He ordered VBH
disqualified from the bidding.
Late last year, the $100 million contract
was awarded to Medco.
But the saga doesn’t end there. In a recent
press release, VB1I announced they intended
to ask the Iowa District Court for a judicial
review and a stay of the contract award by
the Iowa Department of Human Services.
The DIIS, said the press release, denied
VBH’s protest of the Medco award. The 11-
page protest was filed with the DIIS in early
December. Value objected to the DIIS with-
drawal of its original contract award and the
awarding of the contract to Medco.
According to the VBH press release, three
other unsuccessful vendors also plan to file a
motion for a judicial review.
Sound off on RBRVS
The Health Care Financing Administration
(IICFA) wants help reviewing its resource-
based relative value scale.
The deadline is 60 days after IICFA pub-
lishes the request in the Federal Register,
which was published December 8.
In the first such review, IICFA will consid-
er comments on the relative value units asso-
ciated with all physician services and proce-
dures. RVUs measure the amount of physi-
cian work entailed and are used to calculate
payment.
Be sure to reference the appropriate
Current Procedural Terminology code and
the current RVU for the service in question. If
you fail to do this, your comments may not
be considered.
Send one original and three copies to:
IICFA, Health and Human Services Dept.,
Attention: BPD-789-FC (5-year refinement),
PO Box 26688, Baltimore, MD, 21207.
IICFA will consider all comments as it
develops proposed changes, which will be
published in the Federal Register in 1996.
Changes will go into effect January 1, 1997.
For more information on how to sound off
on the RBRVS, contact Barb Heck of the IMS
staff, 800/747-3070 or 515/223-1401.
Medicaid MediPASS program update
The Iowa Department of Human Services
operates two managed health care options:
MediPASS and IIMOs. There are two HMOs
enrolled in the Medicaid Managed Health
Care Program — Heritage and Care Choices.
Current MediPASS counties which are
adding Care Choices IIMO are O’Brien,
Buena Vista, Palo Alto, Pocahontas and Sac.
MediPASS and Care Choices will be imple-
mented at the same time in Sioux County.
Current MediPASS counties which are
adding Heritage are Dallas, Jasper, Madison,
Marion and Warren.
CHMIS update
The Community Health Management
Information System Governing Board and its
five offshoot committees are continuing to
meet to hammer out details of CHMIS imple-
mentation in Iowa.
CHMIS will be implemented in three phas-
64 Iowa Medicine Volume 85/ 2 February 1995
CURRENT ISSUES
es in Iowa. As of July 1, 1996, all health care
providers must submit claims electronically
using a universal claim format. Other phases
of Cl IMIS implementation will require further
action by the Iowa Legislature and involve
reporting of various data to a central reposi-
tory and use of electronic patient records.
Many details regarding how the CI1MIS will
work have yet to be determined by the
Governing Board and five subcommittees.
One subcommittee — the Technical
Advisory Committee — met in December and
decided to divide into two groups which will
study 1) certification standards for networks
and 2) base specifications for the CIIMIS data
repository.
The CIIMIS Ethics and Confideniality
Committee also met recently and will break
into four groups to study various issues
including consumer knowledge of data col-
lected from patient records, legal issues and
who should be granted access to the CIIMIS
data bank.
The Quality Review Committee is dis-
cussing elements of the UB 92 claim form to
determine the uniformity among payers.
Meanwhile, the Iowa Medical Society has
its own CIIMIS committee which is directing
efforts to educate Iowa physicians. IMS staff
have scheduled a number of educational
meetings around the state during the next
few months.
The following CIIMIS educational meetings
have been scheduled:
February 13
Skiff Medical Center
Newton
February 17
la Assc of County
Medical Examiners
IMS
February 20
Cass County Hospital
Atlantic
March 7
Scott County Med Soc
Davenport
April 7
Iowa Psychiatric Soc
DM Marriott
April 22
Iowa Clinical Society
of Internal Medicine
Univ of Iowa
May 6
Iowa Urological Soc
University Park
Holiday Inn, DM
For information on scheduling a CIIMIS
presentation by IMS staff, call Donna Bottorff
at IMS, 800/747-3070 or 515/223-1401. IE]
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Iowa Medicine Volume 85 / 2 February 1995 65
Iowa [Medicine
Practice Management
AT A GLANCE
Enrollment continues in
the IMS Services Medi-
cal Business Specialist
(MBS) program. Anyone
enrolling during the
first quarter of this year
can receive credit for
classes taken during
1994. MBS is a certifica-
tion program for med-
ical office staff, covering
10 broad areas of med-
ical office operations.
The program began in
March of 1994. For
information on how to
enroll, call Mary Reins-
moen at IMS Services,
800/728-5398 or 515/
223-2816.
•
Does your office know
about CHMIS require-
ments which will go
into effect July 1, 1996?
Check out this month’s
Medical Economics sec-
tion for more informa-
tion.
Thirty graduate from MEP
Certificates were presented to the gradu-
ates of the first Management Education
Program (MEP) at a closing ceremony
Saturday, December 17 at IMS headquarters
in Des Moines.
Thirty participants completed a 12-month,
120-hour “mini MBA” program that prepares
them to understand and handle the business
side of medical practice and to be leaders in
the changing field of medicine.
Participants in the MEP received 120
Category 1 CME credits. Several eligible
administrators are planning to sit for their
American College of Medical Practice execu-
tive certification examination in February.
The second MEP, open to any physician or
medical practice administrator, will begin
March 24-25. The program will be limited to
36 participants. Watch your mail for a
brochure and registration details. Or, for
more information call Mary Reinsmoen, prac-
tice management coordinator, 800/728-5398
or 515/223-1401.
MEP December graduates are:
Julie Barto
Siouxland Women’s Health
Center
Sioux City
Juanita Beal, RN
Neurological Center of Iowa
Des Moines
Bruce Bedell, MD
Medical Care Choices
Sioux City
Jim Burke, MD
Center for Family Medicine
Marshalltown
Denise Chaffee
Family Practice Center
Cedar Rapids
Pamela Clemons
Robert Clemons, Jr., MD
Boone
Teresa Dilts
Miller Orthopaedic
Council Bluffs
Beth Ehlers
Associates in OB and GYN
Mason City
Lee Fagre, MD
Family Health Center
Waverly
Angela Fuller, RN
Associated Medical Arts
Waterloo
Greg Harter, MD
Covenant Clinic
Waterloo
Barb Heck
IMS Services
West Des Moines
Denise Kaestner
North Liberty Family Health
Center
North Liberty
Sandra Kouba
Oncology Associates
Cedar Rapids
David Lemon, MD
Methodist Hospital
Des Moines
Robert Mason
Mercy Family Care Network
Mason City
Gerald McGowan, MD
Family Practice Residency
Training Program
Sioux City
Jay Mixdorf, MD
Mercy Family Care Network
Mason City
Thomas Pattee, DO
Covenant Clinic
Waterloo
Gary Peasley, MD
Marshalltown
Pam Robus
Pella Medical Center
Pella
Carol Roge, MD
Siouxland Medical Education
Foundation
Sioux City
Terrie Sandmire
Oto-Head & Neck Surgery
Des Moines
Jeanette Sargent
Physicians Clinic of West
Central Iowa
Carroll
Kim-Marie Schulze
Dermatology Clinic PC
Des Moines
Cindy Snedigar
Family Practice
of Washington
Washington
David Stilley, MD
Broadlawns Hospital
Des Moines
Marge Tully
WL Dull, MD, PC
Iowa City
Julie Warner
United Behavioral Systems
Des Moines
Duane Whitaker, MD
University of Iowa
Iowa City
Good Reviews for IMS Management Education Program (MEP)
“Health care economics could be a very boring topic but the speaker did an excellent job.” Dr. Greg Harter.
“Best presentation on marketing I’ve seen. Excellent instructor, practical and humorous.” Dr. Duane Whitaker.
“Outstanding and instructive. Lots of information, the time went fast.” Marge Tully.
For more information on any seminar, call Mary Reinsmoen or Sherry Johnson at the IMS, 515/223-1401 or
800/728-5398.
66 Iowa Medicine Volume 85 / 2 February 1995
ICD-9-CM
Coding
*t
| A coding course stressing the rules and
guidelines of ICD-9 Volumes 1 and 2 and
applications to case studies.
Burlington Medical Center, Conference Room #4
Marian Medical Services, Classroom B, Sioux City
Marian Medical Services, Classroom B, Sioux City
St. Luke’s Hospital, STL Resource Center Formal
Lounge, Cedar Rapids
Marshalltown Medical & Surgical Center,
Conference Room A
Presenter: Mary Pat Wohl ford- Wessels, MA, MS, RRA, director of Health
Care Administration, University of Osteopathic Medicine and Health
Sciences, Des Moines.
Please bring Volumes 1 and 2 of your ICD*9*CM books.
Wed., March 8
Wed., March 15
Thurs., March 16
Wed., March 22
Tues., March 28
CPT
Coding
g A coding course stressing the rules
_ and guidelines of the CPT manual
I and application exercises.
Burlington Medical Center, Conference Room #4
Marian Medical Services, Classroom C, Sioux City
Marian Medical Services, Classroom C, Sioux City
St. Luke’s Hospital, STL Resource Center Formal
Lounge, Cedar Rapids
Marshalltown Medical & Surgical Center,
Conference Room A
Presenter: Mary Reinsmoen, coordinator of Practice Management, IMS
Services, West Des Moines.
Please bring your 1995 CPT book.
Thurs., March 9
Wed., March 15
Thurs., March 16
Thurs., March 23
Wed., March 29
Tues., March 21
IMS headquarters, Taylor Room, West Des Moines
ICD*9*CM and
CPT Coding
Combination
1 This seminar will offer 3 hours each
■ of ICD»9 and CPT in a one day con-
densed version.
Presenters: Mary Pat Wohlford-Wessels, MA, MS, RRA, director of
Health Care Administration, University of Osteopathic Medicine and
Health Sciences, Des Moines; and Mary Reinsmoen, coordinator of
Practice Management, IMS Services, West Des Moines.
Please bring Volumes 1 and 2 of your ICD»9*CM books and your 1995 CPT
book.
These all day seminars begin at 9:00 a.m. and end at 4:00 p.m. Lunch and breaks with refreshments will
be provided.
The cost is $150.00 for an IMS member or staff and $240.00 for non-member or staff.
★ These programs are part of the IMS Medical Business Specialists (MBS) Certificate Program.
Registration Form
CPT ICD9 Combination
Name(s):
Clinic/Practice Name:
Address:
Phone: Fax:
Amount Enclosed: Date and Location:
Please make checks payable to IMS Services. Mail check and registration form to:
IMS Services ATTN: Sherry Johnson, 1001 Grand Avenue, West Des Moines, LA 50265-3599.
CURRENT ISSUES
Midwest Medical Insurance Company Focus on Risk Management
Informed consent
Informed consent is the result of an educa-
tional process between the physician and the
patient. The physician’s duty is to provide suf-
ficient information to enable the patient to
make an informed decision regarding treat-
ment. The patient’s role is to understand and
evaluate the information and give actual con-
sent to — or refuse — the treatment.
Explaining the risks and benefits of treat-
ment options during the informed consent dis-
cussion can prevent confusion, improve
patient compliance and reduce the chance of a
lawsuit. A significant number of malpractice
claims are precipitated by a patient’s surprise
over unexpected adverse outcomes and inade-
quate physician-patient communication.
Failure to disclose material risks is seldom a
primary allegation in a malpractice claim.
However, it is a secondary element in many. To
help minimize your liability risk:
•Distinguish a patient’s written authoriza-
tion for treatment (the form) from the
informed consent (the process).
•Do not delegate the responsibility for
obtaining informed consent — it is the physi-
cian’s duty.
•Utilize patient education materials and
audiovisual aids to help the patient under-
stand.
•Document the informed consent discus-
sion in the clinic medical record.
For further information, contact Lori Atkinson,
MMIC risk management coordinator, MMIC West
Des Moines office, PC) Box 65790, West Des
Moines, 50265, 800/798-9870 or 515/223-1482.
eimbursement for DME
By January 1, 1996, suppliers of durable
:dical equipment (DME) will not be reim-
rsed for these items unless they have a
dicare supplier number. A supplier cannot
tain a supplier number without meeting
■-determined uniform national standards.
Suppliers may distribute to physicians or
leficiaries a certificate of medical necessi-
vvhich contains no more than the following
ormation provided by the supplier:
•An identification of the supplier and the
neficiarv to whom such equipment or sup-
es are furnished.
•A description of the equipment/supplies.
•Any product code identifying the medical
juipment or supplies.
•Any other administrative information
>ther than the information relating to the
mefieiarv’s medical condition) prescribed
the Secretary.
The American Medical Association sup-
>rted clarification of the Certificate of
edical Necessity requirements to allow the
ipplier to provide product information.
January issue of Iowa Medicine):
5. Amount and/or Complexity of Data to
be Reviewed: change the next documenta-
tion guideline (the fourth one) to:
“Relevant findings from the review of old
records and/or the receipt of additional histo-
ry from the family, caretaker or other source
should be documented. If there is no relevant
information beyond that already obtained,
that fact should be documented. A notation of
‘old records reviewed’ or ‘additional history
obtained from family’ without elaboration is
sufficient.”
6. Risk of Significant Complications,
Morbidity and/or Mortality: change the
fourth documentation guideline to:
“The referral for or decision to perform a
surgical or invasive diagnostic procedure on
an urgent basis should be documented or
implied.”
7. Table of Risk: Under “presenting prob-
lems”, in the High Level of risk category, add
the word “may” to the second bullet, to read,
“Acute or chronic illnesses or injuries that
may pose a threat ...” QJ]
ICFA’s E & M
documentation
guidelines
are final and
appeared in the
Part B News Extra
November 28.
CFA E & M Code documentation
Since the IMS Services EkM coding sem-
tars, there have been the following changes
i the final guidelines (continued from
Iowa Medicine Volume 85 / 2 February 1995 67
Iowa [Medicine
Newsmakers
AT A GLANCE
Dr. Campbell Watts,
Cedar Rapids general
surgeon, has written the
book Defending the Breast
Cancer Malpractice Case
with Cedar Rapids trial
lawyer, David Elderkin.
This is the first book writ-
ten jointly by members of
the two professions.
— •
The Center for Family
Medicine in Marshall-
town and the Jeffer-
son Clinic recently
merged with McFar-
land Clinic. Including
the Jefferson and Mar-
shalltown locations,
McFarland has offices in
eight central Iowa com-
munities.
-•
On the manpower
front, a $50,000 bonus is
being offered to two or
three family practice or
internal medicine spe-
cialists who are willing
to team up with either
one of two clinics or any
solo practitioner in
Maquok-eta. The incen-
tive is being offered by
the Jackson County Pub-
lic Hospital and would
be spread over afive-year
period.
Awards, appointments, etc.
Dr. Michael Emery was recently certified by
the American Board of Plastic Surgery and
became a member of the American Society of
Plastic and Reconstructive Surgeons. Dr. Mary
Kemen, Cedar Rapids anesthesiologist, was rec-
ognized at the YWCA’s 13th annual Tribute to
Women of Achievement, held at the Five Sea-
sons Hotel, Cedar Rapids. Dr. William Galbraith,
associate of internal medicine at the U. of I.
College of Medicine, received the 1994 Inter-
nist of the Year Award from the Iowa Clinical
Society of Internal Medicine. The award recog-
nizes excellence in practice and community
service. Dr. Linda Railsback, ob/gyn director at
Broadlawns Medical Center in Des Moines, has
been selected by the American Medical Women’s
Association (AMWA) to receive the 1994 Com-
munity Service Award. The award honors
AMWA physicians from all over the country
who have given outstanding volunteer service
to their local communities. Dr. Donald Bur-
rows, Des Moines pulmonary diseases and in-
ternal medicine specialist, has become an ac-
credited clinical polysommnographer after pass-
ing the national examination by the American
Board of Sleep Medicine. lie is the only accred-
ited polysommnographer in Des Moines and
one of only three in Iowa. Dr. John Maksen,
Des Moines, has become board certified in
cytopathology by the American Board of Pa-
thology. Dr. Yogesh Shah, Mount Ayr, is now
providing obstetric care to Ringgold County.
Obstetric care had not been available in the
county since August 1992. St. Paul Fire and
Marine Insurance Company’s Medical Services
division has instituted a program which allows
retired volunteer physicians to continue to
serve patients. The St. Paul’s Retired Volunteer
Physician program offers basic and affordable
coverage for former physician professional li-
ability policyholders of St. Paul. Dr. Craig Th-
ompson, Strawberry Point family physician,
was named Physician of the Year by the Iowa
Osteopathic Medical Association. Dr. Donald
Nelson, assistant directorof Cedar RapidsMedi-
cal Education Program, was elected chairman
of the American Society for Testing and Mate-
rials Committee, which is a technical standards
writing committee on computerized systems.
Dr. Monte Skaufle, director of the Mercy/St.
Luke’s Family Practice Residency Program in
Davenport, was presented the Iowa Family Prac-
tice Educator of the Year award during the Iowa
Academy of Family Physicians’ 46th Annual
Meeting and Scientific Assembly in Des Moines.
At that same meeting, Dr. Kelly Ross, Saint
Ansgar, was recently awarded the 1994 Iowa
Family Doctor of the Year. Dr. Corrine Ganske
has been named the associate director of the
Family Practice Residency Program at Iowa
Lutheran Hospital, Des Moines. Dr. Charles
Davis, U. of I. associate professor of preventive
medicine and environmental health, has been
appointed to the editorial board of Controlled
Clinical Trials, the official journal for the Soci-
ety of Clinical Trials. Dr. Davis has also been
appointed to a three-year term on the executive
committee of the Biopharmaceutical Section of
the American Statistical Association. Dr. Jon
Lemke, U. of I. associate professor of preven-
tive medicine and environmental health, has
been elected to the governing board of the
American Public Health Association.
New members (as of September 1994)
Des Moines
John Ankeny, DO, family practice, emergency
medicine
Majed Barazanji, MD, family practice
Scott Carver, MD, family practice
Robert Clark, Jr., MD, general surgery
Philip Clevenger, DO, family practice
Kevin Crowe, MD, cardiology
Jeffrey Davick, MD, orthopaedic surgery
Karl Digman, MD, diagnostic radiology
John Eley, DO, resident
Richard Evans, DO, general practice
John Fell, DO, family practice
Michael Hart, MD, otology, neurotology
Robin Hartley, DO, family practice
Calvin Hansen, MD, neurology
68 Iowa Medicine Volume 85 / 2 February 1995
CURRENT ISSUES
Kathleen Hansen, MD, pathology
Christine Holm, MD, oncology
Douglas Horsington, DO, otolaryngology
Mark Jones, DO, general practice
Kathleen Lange, MD, resident
Kathryn Lynn, DO, internal medicine
Brian Mehlhaus, MD, family practice
Randy Maigaard, MD, internal medicine
Eden Murad, DO, family practice
Jeffrey Nichols, DO, anesthesiology
Daphne Panagotaeos, MD, dermatology
Wesley Richardson, DO, psychiatry
Catherine Rook-Roth, DO, family practice
Pricilla Ruhe, MD, family practice
David Sandercoek, DO, resident
Bryon Schaeffer, MD, resident
Douglas Selover, DO, pediatrics
Theresa Smith, MD, internal medicine
Larry Standing, DO, family practice
Jacqueline Stoken, DO, physical medicine and
rehabilitation
Susan Wilkinson, MD, infectious diseases
Dubuque
Joseph Compton, MD, internal medicine
Joseph Jenkins, MD, general surgery
Stephen Pierotti, MD, orthopaedics
Thomas Schreiber, MD, family practice
Fort Madison
Mark Reynolds, MD, ophthalmology
Grimes
Douglas Layton, DO, family practice
Grinnell
Clayton Francis, MD, family practice
Guy McCaw, MD, family practice
Indianola
Daniel Miller, DO, family practice
Rene Staudacher, DO, family practice
Deceased members
Dallas Minchin, MD, 66, anesthesiology,
Council Bluffs, died November 16
Paul, Stitt, MD, 80, life member, general
surgery, Fort Dodge, died October 9
Joseph Weyer, MD, 86, life member, obstet-
rics/gynecology, Fort Dodge, died October 25
Irving Hanssmann, MD, 88, life member,
internal medicine, Council Bluffs, died July 23
Craig Ellyson, MD, 86, life member, family
practice, Waterloo, died November 23 [El
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Iowa Medicine Volume 85 / 2 February 1995 69
Iowa|Medicine
Domestic violence: the law
and physician liabilities
Statistics and studies present staggering proof that domestic violence is a medical-legal
issue of major proportions. Domestic violence almost always is an assault (physical, psy-
chological or sexual) committed by male partners against women. Lest anyone believe
domestic violence is an urban ill, the U.S. Department of Justice National Grime
Victimization Survey concluded that women living in central cities, suburban areas and
rural areas experience similar rates of violence by intimates.
It is estimated that between 20,000 and 44,000 Iowa women suffer abuse in their homes
every year. Between 1990 and 1994, 33 Iowa women were murdered by husbands and
boyfriends. The Iowa Judicial Department reports that the number of domestic abuse civil
filings rose from 188 in 1990 to 2,677 in 1993 alone. Domestic violence projects in Iowa
provided shelter to approximately 8,000 women and children in 1993.
In a way, domestic abuse is a silent epidemic. Of the women who were physically abused
by their partners, 92% did not discuss the abuse with their physicians and 57% did not dis-
cuss the incident with anyone. A study of a family practice clinic in the Midwest revealed
that 38.8% of the women respondents had been physically assaulted by their partners but
only six of these women had been asked about domestic violence by their physician.
Jeanine Freeman, .11)
Ms. Freeman practices
with the firm of
Dickinson, Mackaman,
Tyler and Hagen, PC in
Des Moines. She was
formerly an attorney
for the Iowa
Hospital Association.
Iowa Legislature addresses domestic abuse
The medical and legal communities in Iowa have sought to respond to this crisis. In
1991, the Iowa Legislature passed comprehensive legislation addressing domestic abuse
which 1 ) made it easier for victims to seek protective orders and provided for better notice
of the protective order to law enforcement; 2) required hospitals to develop protocol for
identifying and responding to the needs of domestic violence vietims; and 3) emphasized
the development of various programs for assisting victims.
In 1993, the Iowa Supreme Court established a Task Force on Courts’ and Communities’
Response to Domestic Abuse calling for a cooperative response by the courts and commu-
nities. The Task Force’s final report set forth 76 recommendations, including exhortation
to the medical community to participate in statewide and local community efforts. The
Iowa Medical Society, the Iowa Hospital Association and the Iowa Coalition Against
Domestic Violence developed domestic abuse protocol for use by hospital emergency room
physicians and personnel. (These protocol are available to IMS member physicians by call-
ing Becky Roorda at the IMS, 800/747-3070.)
Domestic abuse is a crime
Iowa law is unequivocable — domestic abuse is a crime. Depending upon the severity of
DOMESTIC VIOLENCE ISSUES
the assault, domestic abuse is punishable as a simple, aggravated or serious misdemeanor. Iowa
law does not distinguish in punishment between domestic and other situations involving the
commission of sexual abuse, infliction of serious physical or mental harm, or homicidal acts.
It is important for physicians to recognize domestic abuse is a crime in order to under-
stand their legal duties in reporting to law enforcement authorities. Physicians also have
regulatory and professional responsibilities to cooperate with community service agencies
in providing for victim safety. Physicians play a key role in identifying a patient as a victim
of domestic abuse, in establishing intervention and treatment plans that reflect the unique
care needs of victims and in referring the victim to law enforcement and community assis-
tance agencies for support that is beyond the expertise of the medical community.
While physicians believe that greater involvement by them with victims of domestic vio-
lence enhances their exposure to legal liabilities, the law and professional ethics often
require such involvement, with failure to do so posing the greater risk of liability.
Reporting to law enforcement agencies
Confusion has reigned regarding reporting responsibilities for domestic abuse under Iowa
law. When the General Assembly passed its domestic abuse reform legislation in 1991, it
specifically rejected mandatory reporting of all instances of domestic abuse to law enforce-
ment by hospital emergency room personnel. That legislative judgment call was in accord
with the view of victims’ advocates as well as principles of medical ethics, emphasizing
respect for patient autonomy and confidentiality. Victims will often forego medical treat-
ment rather than run the risk of a filed report with law enforcement.
In 1993, the Iowa Legislature amended Iowa’s law on reporting wounds of criminal vio-
lence to require reports of gunshots, stab wounds or other serious bodily injuries received
in the course of the commission of a crime. As already noted, domestic abuse is a crime.
This narrower approach to reporting is supported by victim advocates.
Iowa Code §147.111 and its reporting responsibilities apply directly to Iowa physicians.
Commonly asked questions are:
1. Who must report? Health care professionals who administer treatment (or from
whom treatment is sought but not administered) to any person suffering a gunshot or stab
wound or other serious bodily injury.
2. Under what circumstances should a report be filed? Where it appears that the gun-
shot, stab wound or other serious bodily injury was incurred in connection with the com-
mission of a crime. Serious bodily injury is a bodily injury which creates a substantial risk
of death or which causes serious permanent disfigurement or protracted loss or impairment
of the function of any bodily member or organ.
3. When and to whom should the report be made? Required reports shall be made “at
once but not later than 12 hours” after application for treatment was made or treatment
was provided. Reports shall be made to the appropriate law enforcement agency where
Professional ethics
often require such
involvement, with
subsequent failure
to do so posing the
greater risk of
legal liability.
References
Available
References for this article
are available from the
editors of Iowa Medicine.
Iowa Medicine Volume 85 / 2 February 1995 71
Iowa |Medicine
if physician
failing to make a
required report
shall be guilty of
a simple
misdemeanor.
treatment was provided or, it’ ascertainable, where the injury was received.
4. What must be reported? The report is simple: the person’s name, the person’s resi-
dence and a brief description of the gunshot, stab wound or other serious bodily injury.
5. Is patient consent required before a report is filed? So long as the report fits the def-
inition of a required report under §147.111, patient consent is not necessary. The statute
states “any provision of law or rule of evidence relative to confidential communications is
suspended insofar as the provisions of this section are concerned.” The AMA recommends
the physician inform the patient of the legal responsibility to report, explain investigation
and follow-up procedures and address the risk of reprisal and possible need for shelter.
6. Is reporting required only where the injured person presents at the hospital emer-
gency room? The statute makes no distinctions between sites, and places the responsibili-
ty on the health care professional regardless of where the treatment is provided.
7. What happens if a physician fails to report? Any person failing to make a required
report shall be guilty of a simple misdemeanor, punishable by imprisonment not to exceed
30 days or a fine of at least & 50 but not more than 8100. Also, a physician may incur legal
liability if the physician fails to make a required report and the patient suffers further harm
that could have been prevented if law enforcement had been notified as required by law.
8. What are the legal protections for making reports? The law does not provide specif-
ic legal protection from civil and criminal liability for filing good faith reports under this
reporting requirement. In that regard, §147.1 1 1-. 113 is different from Iowa’s reporting laws
on child and dependent adult abuse. Section 147.111 does, however, suspend confidential-
ity interests where a required report is made; this serves as legal protection to physicians
filing reports that meet the definition of the statute.
9. Suppose a physician makes a report, believing in good faith that the injury met the
requirements of the statute but, upon investigation, these conclusions are shown to be
incorrect? So long as the physician filed the report in good faith belief that the report was
required or that other interests such as patient or physician/staff safety demanded protec-
tion and the report was not filed for improper motives, Iowa case law supports the physi-
cian s judgment call.
10. Can a physician permissively report an injury other than those defined by
§147.111? Generally, no. Unlike Iowa’s reporting laws on child abuse and dependent adult
abuse, this section of the Code does not specifically authorize permissive reporting without
patient consent.
A physician who files a report of domestic abuse which falls outside the scope of required
reporting under §147.11 1 without the patient’s consent clearly runs a legal risk. There may
be instances, however, in which a report to law enforcement is necessary to protect the
immediate safety interests of the patient, the patient’s family or the physician and the staff
of the physician or hospital. In such instances, confidentiality interests likely give way to
immediate safety needs. Any risk of liability for reporting in such an instance is clearly min-
imized if only information essential to the report is provided. Of course, a report is autho-
72 Iowa Medicine Volume 85 / 2 February 1995
DOMESTIC VIOLENCE ISSUES
rized if the patient has knowingly given consent to the filing of the report.
11. To what extent should a physician cooperate with a follow-up investigation by law
enforcement officials? Again, unlike other Iowa mandatory reporting laws, no provision is
made within §147. 111-. 113 for physician cooperation with law enforcement officials con-
ducting an investigation based on the report. Furthermore, §147.111 suspends confiden-
tiality requirements only for purposes of filing the required report and does not specifical-
ly relate to release of information in the course of investigation by law enforcement.
Law enforcement officials have no absolute right to medical information even where that
information is necessary to investigate a crime. Interestingly, §147.112 specifically states
that law enforcement authorities shall not divulge any information either received by them
in a report made under §147.111 or gathered by them in a follow-up investigation except to
other law enforcement officials and then only in connection with investigation of the alleged
crime. This provision indicates a legislative intent to balance practitioner concerns with
confidentiality — whether information is released via report or investigation — with the
need for information.
The law in this area, however, is unclear and each situation presents a different measure
of legal risk. A physician is always best advised to release otherwise confidential infor-
mation to investigative authorities only with patient authorization. Any release of infor-
mation without patient consent is done at legal risk. Some information may not be medical
or treatment information and, therefore, not specifically governed by either confidentiality
or privilege, but physicians are generally not in a position to make such judgment calls.
Physicians should err on the side of confidentiality. If the victim refuses to consent to
release of information to law enforcement, physicians are advised to release such informa-
tion only pursuant to an order of a court, which, while cumbersome and time-consuming to
investigators, protects physician and patient interests. If the patient has died, the legal risks
in releasing information related to the matter under investigation are clearly minimized.
Reporting issues under Iowa law require judgment calls relative to the nature of the
injury and other matters before a report is or is not filed. Physicians should document their
decision to report or not report and their medical findings supporting that decision.
Physicians must also be aware of hospital policies and protocols for reporting and abide by
them. Physicians should advise their office staff regarding reporting in the event patients
who are victims of domestic abuse present to the clinic or office setting.
Physician responsibilities under hospital protocol
As a result of the 1991 domestic abuse legislation, Iowa law and regulations of the Iowa
Department of Inspections and Appeals require hospitals to have in place protocol for
responding to the needs of domestic violence victims. These requirements are consistent
with standards of the Joint Commission on Accreditation of Health Care Organizations
(JCAIIO). JCAHO and Iowa law focus on identification of patients who are victims of
domestic violence, privacy in interviews, patient consent and confidentiality, information
No provision is
made for physician
cooperation with
law enforcement
officials conducting
an investigation
based on the
report.
Iowa Medicine Volume 85 / 2 February 1995 73
Iowa |Medicine
A physician who
fails to abide by
recognized
protocol could be
held liable for not
living up to what is
now a duty, stated
in law.
on community resources, preservation of evidence and record keeping.
Neither hospital licensure regulations nor JCAHO standards specifically apply to physi-
cians, therefore physicians cannot be disciplined under them. However, medical staff rules
and regulations generally require physician compliance with hospital policies. Physicians
also operate at legal risk in failing to adhere by hospital policies and protocol where such
failure ultimately results in harm to the patient. Physician coordination with hospital poli-
cy and protocol is essential.
Confidentiality — be cautious about disclosing information
Victims of domestic violence deserve the same level of physician-patient confidentiality
as any other patient. The only specific Iowa statutory exception to confidentiality is for
required reporting noted above. Physicians should be particularly cautious about disclosing
information to a partner of the victim who could be the abuser. Regulations mandating hos-
pital protocol provide for confidentiality of “the person’s treatment and information”, cre-
ating a wide berth for confidentiality and heightened possibilities of liability for failure to
abide by confidentiality requirements.
Informed consent
Iowa law is firmly committed to informed consent for patient care. Physicians owe a gen-
eral duty to disclose to their patients all information material to making an informed deci-
sion. Victims of domestic violence remain autonomous medical decision makers and may
refuse treatment or intervention proposed by the physician. At the same time, part of assur-
ing that the consent is informed may very well require that physicians address safety and
other matters of concern that the victim might harbor regarding a suggested plan.
Physician duties to patients who are victims of domestic abuse
Physicians generally owe a duty to their patients to obtain informed consent and to pro-
vide care and treatment in accordance with recognized medical standards. Questions arise
whether newly-developed legal, regulatory and professional emphasis on the physician’s
role in domestic abuse situations creates additional duties for physicians, breach of which
may result in liability.
Potential liabilities arise within the context of patient care and negligence in not adher-
ing to medical standards in providing such care. In the same way, a physician who fails to
abide by recognized protocol for identification and referral of a patient as a victim of domes-
tic violence could be held liable for not living up to what now is a duty stated in law and
regulation and which, arguably, has been a long-standing professional responsibility.
Physicians are best protected from the risk of legal liability by familiarizing themselves
with applicable protocol and adhering to them, by providing necessary medical care, by pro-
viding information to victims regarding legal and community assistance, by respecting
patient autonomy and confidentiality and by making required reports. Physicians should
74 Iowa Medicine Volume 85 / 2 February’ 1995
here’s to your
Hemth
A patient’s guide to better health
Provided by the Iowa Medical Society
Domestic
Abuse
an information &
referral guide for
battered partners
A letter to battered women
Unfortunately, violence is a part of many women’s lives. If you are
being abused, you are not alone. Millions of women are battered by
their partner. If you are unsure whether you are being abused, ask
yourself if your partner’s behavior includes any of the following:
• pushing, shoving, slapping, hitting, kicking, choking, throwing
objects at you
• put-downs, name-calling, accusations, mind games
• destroying property, threatening your children
• threatening suicide, threatening to report you to the authorities
• controlling all the money, not allowing you enough money for
family or personal expenses, preventing you from getting a job
• forcing sex against your will, physically attacking the sexual parts
of your body, accusations that you are having sex with another
partner
Insert to Iowa Medicine, February 1995
Abusive behavior usually increases in frequency and severity over
time. Remember, the abuse is not your fault. Violence is used to gain,
maintain and regain power and control. It is used to lower your self-
esteem and limit your resources so you don’t feel you can safely leave
the abuser. (See pages 2 and 3 of this insert for safety planning ideas
you may want to consider if you are planning to leave the abuser.)
There are resources and options available to assist you in getting
away from the violence. For information regarding shelter services,
counseling, support groups, court advocacy and safety planning call
the Iowa Domestic Abuse Hotline, 1-800/942-0333. All contacts with
any domestic violence project will be kept confidential.
You know what is best for yourself and your children. Use the skills
and resources you have to leave the violence when you are ready. No
one deserves to be abused.
Laurie Schipper, Iowa Coalition Against Domestic Violence
IOWA MEDICAL SOCIETY
The Iowa Medical Society’s
most important and long-
standing goal is protecting
the health of lowans through
a variety of projects and
activities. IMS members play
a significant role in formulat-
ing policy and publishing
educational materials on key
public health issues such as
tobacco use, rural health care
and domestic abuse.
What Is domestic violence or abuse?
Domestic violence is physical, emotional or sexual abuse
that occurs between two people who are, or were, in an
intimate relationship (spouse, ex-spouse, lover or dating
partner). It is a pattern of abusive behavior used to
control one’s partner. Refer to page 1 for some examples
of abusive behavior. Other abusive behavior includes:
• isolating you from friends or family
• controlling who you spend time with and where you go
• trying to keep you from driving by tampering with your
car
• forcing your car off the road or trying to run you over
• displaying weapons in a threatening way
• threatening to kidnap the children if you leave
• threatening to kill you
Who Is to blame for the violence?
Domestic abuse is a learned response. Many abusers grew
up witnessing abuse or were abused themselves. How-
ever, this does not excuse their behavior. Battering is a
conscious choice the batterer makes as a way to control
another person because it is effective. Domestic violence
is not a mental illness, nor is it caused by substance
abuse — although this may intensify it. The abused per-
son is not responsible for her abuser’s violent behavior.
Part of the abuser’s plan is to lower his partner’s self-
esteem so he can blame her for the abuse: “You make me
beat you by how you act. You deserve to be hit because
you make me mad.”
What can a woman do to stop the violence?
In most cases, the only thing you can do to stop the abuse
is to leave the relationship. Yet, there are risks in fleeing
from the abuser. Each woman must decide what is best
for herself and her children. Remember, the abuse is not
the victim’s fault.
If a woman Is planning to leave her abusive
partner, what preparations should she make?
Following are safety planning ideas a battered woman
may want to consider:
• Save and hide money.
• Make an extra set of house, car, safety deposit box and
other keys. Keep them in a safe place, such as a friend’s
house or at a domestic shelter.
• Hide extra clothes for yourself and your children at a
friend’s house or another safe place.
• Keep any evidence of physical abuse (ripped clothes,
photos of bruises and injuries, etc.).
• Make and hide a file of important documents such as
restraining or no-contact orders, birth certificates,
bank records, school records, insurance papers, food
stamps or AFDC papers, medical records, prescrip-
tions, phone numbers and all Social Security numbers.
• Start talking to people about the abuse — a trustworthy
friend, a shelter staff person, your family doctor, min-
ister or lawyer.
• Practice calling 911 and crisis lines; practice driving to
the police station.
• Teach your children which neighbor to go to and how
to call for help.
• Back the car into the driveway so you can get away
faster. Keep only the driver’s door unlocked.
• Learn to know the coming signs of violence. How long
does it take him to escalate?
• Start doing things like walking the dog or taking out the
trash at odd hours. If an escape is necessary, pretend
you’re leaving to walk the dog and get out. Drive or walk
to a friend’s house, a shelter or police station.
• Arrange a signal with a neighbor; for example if the
porch light is on, call the police.
Will I lose custody of my children if I leave
without them?
No. The fact that you had to flee for your safety does not
mean you do not care about your children. But, if you are
forced to leave them behind, be sure to see a lawyer
immediately. The police and your local shelter can also
be helpful. Keep in mind that the longer you leave your
children, the harder it may be to get them back.
Feelings and defenses of
battered women
Are children affected by partner battering?
The appearance of violence and cruelty threatens the
child’s sense of safety as well as provokes fears for the
safety of his parents. When physicial violence occurs, it
results in a dramatic increase in the child’s fears. A child
who watches a parent being injured frequently develops
symptoms typical of depression, like crying spells and
regresses to behaviors such as bed wetting, thumb suck-
ing and withdrawal. A child who witnesses the abuse of a
parent over the long term frequently develops problems
with loyalty, initially aligning himself with the abused
parent and later identifying with the abuser. A child may
take the position that daddy beat up mommy because
“mommy deserves it.” Also, a common side effect of
chronic domestic violence in the home is abusive and
controlling behavior by the child.
Is battering a crime under current law?
Yes. Any act intended to cause you pain or injury, or
which is intended to place you in fear of immediate
physical contact, or which involves pointing a firearm
toward you or displaying a dangerous weapon in a threat-
ening manner is a crime. You need not have visible
injuries or broken bones to call for police protection.
Law enforcement officers must now use all reasonable
means to prevent future abuse, including arranging to
take you to a safe place or a medical facility or remain
with you until the threat of violence ends. An officer must
arrest your abuser when there is reason to believe you
have been hurt or someone intended to seriously injure
you or has displayed a dangerous weapon in a threatening
manner. Also, if the person assaulting you is in violation
of an order issued by the court, the officer must make an
arrest.
This information on domestic abuse has been
compiled from publications of the Iowa Coa-
lition Against Domestic Violence, Children &
Families of Iowa, Family Resources, Inc. and
the Iowa Medical Society. As a service to
IMS member physicians, this insert may be
photocopied for placement in clinic recep-
tion areas. Original inserts may be purchased
from the IMS for 15 cents each. Call Jane
Nieland or Bev Corron at the IMS, 515/223-
1401 or 800/747-3070.
If I have a friend who is being battered, how can
I help her?
Your role as helper should be to provide support, assis-
tance and information without judging. Be ready to
listen, but don’t pry for details. Keep things told to you in
confidence, confidential. Direct responsibility for the
violence onto the batterer, not your friend. She does not
deserve to be hurt regardless of the choices she’s made.
Be nonjudgemental, even if you think she has made some
foolish choices.
You may wish to help your battered friend explore
options, but don’t make decisions for her. Help her plan
a safe escape from her home by gathering the things
described on pages 2 and 3 of this brochure. Assist her in
contacting the Iowa Domestic Abuse Hotline (1-800/942-
0333) or a local shelter.
4
DOMESTIC VIOLENCE ISSUES
document all of these matters in patient records. Special considerations also come into play
in treating victims of domestic violence, such as taking proper steps to insure patient safe-
ty. Common sense judgment premised on the patient’s best interests goes a long way to min-
imizing legal liabilities.
Physician’s duty to warn third parties
Physicians sometimes question whether they will be held liable for injuries that occur
once a domestic abuse victim leaves their care and is again subjected to abuse. Iowa courts
have determined that a person generally owes no duty to control the conduct of others
unless a special relationship between them creates such a duty. A relationship giving rise to
a duty of care is necessarily based on the foreseeability of harm to the injured person.
It is not inconceivable that legal action could be brought naming the physician and alleg-
ing some legal duty to have warned law enforcement authorities or some other third party
regarding potential harm to the patient or to another. To date, Iowa case law has not been
quick to find such a duty, particularly where physicians act reasonably, in good faith, in
accordance with legal and regulatory requirements and consistent with standards of care.
Again, knowledge of and compliance with applicable protocol and documentation are key
to avoiding legal liabilities in this arena.
Documentation
Department of Inspections and Appeals rules for hospital protocol on domestic abuse
require that treatment records of domestic abuse victims include assessment information,
proof the victim was informed of telephone numbers for community assistance, medical
care information, notations regarding follow-up care and the victim’s statement of how the
injury was received.
Physician documentation should be consistent with these hospital requirements. In addi-
tion, physicians should note whether a report to law enforcement was made and whether
such a report was made as required by Iowa Code §147.111, or because of concern for
patient safety or the safety of others, or with patient authorization. Greater detail should be
provided where a report outside of §147. 1 11 and without patient consent is made. Accurate
documentation can be an invaluable source of protection against claims of legal liability.
Physician involvement is crucial
The American Medical Association, the Iowa Legislature and a range of public and pri-
vate policy agencies are strongly encouraging (if not requiring) physician involvement in
identification of and assistance to domestic violence victims. Focus on patient care needs,
compliance with medical standards, adherence to the requirements of reporting laws and
regulatory protocol and accurate documentation are the best protections for physicians in
avoiding liabilities as they become essential partners in providing support services to vic-
tims of domestic violence. HE
Accurate
documentation can
be an invaluable
source of
protection against
claims of
legal liability.
Author's note
This article is informa-
tional and is not an
exhaustive study of all
matters of potential legal
liability arising from
working with victims of
domestic abuse.
Physicians with specific
questions should consult
legal counsel.
Iowa Medicine Volume 85 / 2 February’ 1995 75
Curtis Ruby
Mr. Ruby has been a
police officer in Fort
Dodge for 15 years. lie
serves on the Crime
Victim Assistance Board
of Iowa and is a former
board member and co-
chair of the Domestic/
Sexual Assault Outreach
Center public awareness
committee.
Documenting domestic abuse
Proper documentation of known or suspected domestic abuse requires careful observa-
tion and interview techniques. It will take extra time and effort and special insight, but cut-
ting corners might later prove to be a critical mistake.
The physician’s duties and liabilities must always be considered when documenting
cases of abuse. Medical records of the treatment given to a patient may prove to be crucial
evidence in a court of civil or criminal law. Your report might provide the evidence neces-
sary to prevent further violence.
Because domestic violence can be very complex, specialized training is invaluable.
Without it, subtle indicators may be missed, resulting in an inaccurate diagnosis. Staff at
local domestic violence projects are usually happy to present information regarding the
dynamics of domestic abuse at little or no cost. Understanding the patient’s special needs
will enable the medical professional to be more effective, especially during the interview.
Multiple barriers often exist for professionals conducting interviews of domestic abuse
victims. The patient might be overwhelmed with fear and shame. A victim’s behavior can
be misunderstood. The best, single piece of advice is this: Be willing to ask about the
abuse or suspected abuse in a caring , non-judgmental fashion.
There are many indicators of abuse and, if any are noted, inquire about them. Even if
the patient is reluctant or unwilling to cooperate, chances are she will be glad you asked,
despite how it may appear from her outward reaction. Any time you suspect domestic vio-
lence, refer the patient to the nearest domestic violence project and document the fact that
you made the referral. These projects often have available brochures or other information
for patients. (See page 81 for a list of domestic violence projects around Iowa.)
It is vitally important to avoid responding negatively to the victim. If a victim is “revic-
timized” in your office, the chances of conducting a productive interview and beginning the
Medical record documentation
Thorough medical records are essential for preventing further abuse and provide evidence which may prove crucial
to the outcome of a case. If medical records and testimony at trial conflict, the record may be considered more credi-
ble. Records should include:
•Complete medical and social history.
•Detailed description of the injuries including type, number, size, loca-
tion, resolution, possible causes and explanations given. Where applic-
able, record the location and nature of the injuries on a body chart or
drawing.
a. Bruises or burns that have a pattern characteristic of the object
used.
b. Bite marks, scratches, missing clumps of hair.
c. Ligature marks, fingerprints about the neck.
d. Lacerations, especially defense type wounds to hands and arms.
•Chief complaint and description of the abusive event, including a
detailed history of the events leading up to presentation at the hospital.
Use the patient’s own words whenever possible rather than your own
assessment: “My husband hit me with his fist” rather than “Patient has
been abused”.
•An opinion on whether the injuries were adequately explained.
•Results of all pertinent laboratory and other diagnostic procedures.
•Color photos and imaging studies, if applicable.
•If the police are called, the name of the investigating officer and any
actions taken.
76 Iowa Medicine Volume 85 / 2 February 1995
DOMESTIC VIOLENCE ISSUES
process of emotional healing are jeopardized. Hypersensitivity is a reality with any trauma
and physicians should expect absolute professionalism from their staff. Victims are not usu-
ally readily recognized as such and are often not at their best when seeking assistance.
It is important to consider carefully the questions and comments put to a domestic vio-
lence victim. A question such as ‘Why do you tolerate this?’ is judgmental because it implies
you believe she has a choice and is somehow responsible. Asking why the patient waited to
seek treatment sends the same accusatory message. It is almost impossible to avoid some
mistakes during an interview, but the impact is lessened if your approach is sincere and
respectful. Following are suggested questions:
•“I suspect that family violence is a problem here. Are you in a safe relationship?”
•“What happens when you and your partner have a fight or disagree?”
•“I’m concerned about your safety. IIow can I help?”
•“Do you or your children ever feel afraid of your partner?”
Suggestions for documentation are:
•Document in every case, whether or not the police are contacted. If there is police
involvement, be sure to include the name of the investigating officer in the report.
•Whether or not the police are called, handle the case as if the records might someday
be part of an investigation. Disfigurement, disabling injury, feticide, sexual abuse, kidnap-
ping, related child abuse, homicide and suicide far too often occur with domestic violence.
•Photographs should be routine in these cases, but keep in mind this can only be done
with the patient’s written consent. The same applies if searching for further indicators of
abuse using imaging studies. Photographs should be properly dated, marked and handled in
the most confidential manner possible.
Complete documentation and successful intervention depends on the physician’s will-
ingness to take time to explore the patient’s needs. Documenting abuse cases involves care-
ful observations combined with non-judgmental interviewing techniques. Interview the vic-
tim alone, out of earshot of the partner who may be the abuser.
Injuries can be hidden by makeup, clothing or hair and the truth may be concealed by
lies and half-truths. However, the motives are the same — fear, shame and lack of trust. The
physician may prove to be the only hope for a victim of domestic violence. The well-pre-
pared medical record may later be the key to the patient’s safety and future.
Physician testimony
According to the AMA,
for medical records to be
admissible in court, the
doctor should be pre-
pared to testify:
•That the records
were made during the
“regular course of
business” at the time
of the examination or
interview.
•That the records
were made in accor-
dance with routinely
followed procedures.
•That the records
have been properly
stored and their access
limited to professional
staff.
Editor's note
Content, opinions and
instructions in this article
are those of the author and
should not be interpreted as
reflecting the approval, dis-
approval, policy or opinion
of the Fort Dodge Police
Department or any section
or officer thereof.
Taking photographs of domestic abuse injuries
Photographs may be taken with the patient’s permission. Hospital protocol may require that patients sign a consent form.
•The photographer should be the same sex as the patient, if possi-
ble.
•Take photos before medical treatment is given, if possible.
•Include the patient’s face in at least one picture (or, the patient’s
hand holding an identifying document).
•Use color film.
•Mark photographs precisely as soon as possible with the patient’s
name, the date, time and photographer’s name. Consider using a
quality instant camera so photos can be marked immediately.
•Photograph from different angles, full body and close up.
•Take at least two pictures of every major trauma area.
•Use a ruler or other object to illustrate the size of the injury.
•Photographs should be kept in a sealed envelope with the written
statement ‘Confidential ... to be used only by patient’.
Iowa Medicine Volume 85 / 2 February 1995 77
Iowa [Medicine
Laurie Sail peer
Ms. Schipper is executive
director of the Iowa
Coalition Against
Domestic Violence.
Rural battered women
Battered women in rural Iowa often believe that, even if they were to escape the vio-
lence, there would be no one to help and no place to hide from their abuser. The rural expe-
rience presents some unique barriers for battered women and service providers.
The experience of many battered women in rural Iowa
There are several key issues that isolate rural battered women:
•Many rural battered women may not have access to a telephone. If they do have phone
service, many calls may be long distance and, therefore, easily tracked by the abuser.
•There is usually no access to public transportation. This means the woman must rely
on the family vehicle. If there is a vehicle available, batterers often damage it or make sure
it is out of gas.
•Due to geographical proximity, police and medical response may not be timely enough
to assist many rural battered women. It may also be true in some rural areas that law
enforcement, attorneys and judges have not had adequate training in domestic violence.
This can result in inadequate intervention.
•Resources available to help battered women who escape their homes are often limited.
For example, there are few jobs available in rural areas, poor housing and there may be lim-
ited child care, social services and health care.
•Access to the court system can be limited in rural Iowa. In some areas, women must
wait for up to two weeks to get an emergency order for protection because a district court
judge is only in the area once every two weeks. Women are often forced to travel across sev-
eral counties with their children to seek protection from the court.
•Extreme weather conditions may further exacerbate the isolation or the woman’s abil-
ity to escape or seek support.
•Hunting weapons are normal part of farm life. There may be a shot gun or rifle — sel-
dom registered — in the house, barn or truck. Batterers may also have easy access to farm
tools such as axes, saws and chains and may use them to abuse their partner.
•Travel to a larger city may be an additional crisis for a rural battered woman. She may
feel intimidated and unable to cope with a city which appears uncaring or unaccepting.
•Bruises and other injuries sustained by rural battered women may heal before they are
seen by neighbors, family or professionals. Farm machinery may also provide an easy
excuse for injuries which are actually a result of abuse.
•Rural women are often financially dependent on farm income and may have no finan-
cial resources of their own. Often, rural battered women must decide between leaving and
risking the family farm or staying and enduring the abuse.
•Restraining orders are often modified to allow the batterer access to the farm as his only
source of income.
78 Iowa Medicine Volume 85 / 2 February 1995
DOMESTIC VIOLENCE ISSUES
Other barriers for rural women
An additional barrier for rural women is the severe lack of available domestic violence
services. Domestic violence projects in rural areas often serve a five to 10 county area. With
severely limited financial resources and staff, the distances they must cover put a serious
strain on these projects.
It is often difficult to ensure confidentiality for battered women in rural areas. It is com-
mon for a woman seeking assistance to find that the domestic violence advocate meeting
her at the hospital is also her children’s Sunday school teacher or that the police officer
responding to her call is one of her husband’s friends. This makes it more difficult to pro-
vide confidentiality regarding delivery of services and the location of shelters or safe homes.
Many of us have been socialized to view families as private and this is especially true for
rural families who value privacy and rarely seek outside assistance other than from extend-
ed family members. We also have a belief that country life is somehow safer than city life.
Attitudes to the contrary may be met with resistance and ridicule.
It should be noted that rural battered women do escape the violence and go on to live a
violence-free life. However, it is often a difficult and dangerous path. Battered women need
options and resources to assist them with keeping safe and getting out. (For more informa-
tion on services available across Iowa, including a map, see page 80 of this issue.)
Rural Experience bv Lvdia Walker
(published by the National Coalition Against Domestic Violence Rural Task Force)
Often, rural
battered women
must decide
between leaving
and risking the
family farm or
staying and
enduring the abuse.
It’s really
just as you imagine.
The woman
dragging and carrying
two children
is panting as she stumbles
along the deer trail
that leads down back behind
the neighbors.
Inside, with slow deliberation
he is pulling on his boots
and finding the flashlight
and finally,
when she does hear him coming
he is moving much faster
than they can go.
In town,
he catches her again on the way to
the discount store,
and four counties buzz
about the power of the hunting rifle that
blew clean through.
Three of us from the shelter
drive an hour to go over,
and at the funeral,
a man reads the survivors:
first sons, then daughters;
father, then mother;
brothers, sisters;
paternal, then maternal
grandfathers, grandmothers.
The first man to view the body
wears a shiny crimson red windbreaker
with a Taxorback Hog smarling
across his back,
and even some of the pall bearers
don’t wear suit coats — the family is so poor.
But many women have already dropped by
plates of food
to offer hospitality to those
who stop by or call,
and the funeral director’s wife
has put a display of
china cups and china saucers
near the registry.
The woman’s quartet, accompanied by a
slide steel guitar, sings
“Just Inside the Eastern Gate”
and that does seem nice
because she loved country music.
I think it really must be the same • — wife beating
— in the city or the country.
For me, personally,
I can’t tell the difference in
the horror of screaming
and no one coming to help
and the horror of screaming
and no one hearing at all.
Iowa Medicine Volume 85/2 February 1995
79
Iowa [Medicine
Domestic violence programs
The map below shows the locations of domestic violence shelters, safe homes and
crisis lines throughout the state. For more complete information regarding specific
services offered by each program, call Chris Clark of the IMS staff, S00/7 47-3070.
Shelter
Safe Home
Crisis Line
Did you miss last
month’s magazine?
The January Iowa
Medicine was also
dedicated to domestic
violence. If you missed
it or didn’t get your
copy, call IMS head-
quarters.
Referral information
According to the Iowa Coalition Against Domestic Violence, the mission of domestic
violence centers in Iowa is to provide information, resources and advocacy to battered
women to help them make the best choices for themselves and their children. The cen-
ters are committed to helping women in a way and in a time frame that feels comfortable
to them. The battered woman is the expert on how she can stay safe and alive.
If you are working with a woman who has been battered or who you suspect has been
battered, give her good information about what resources are available in her community
to help. Remember, not all battered women will be ready to seek assistance at the time of
referral. This does not mean the referral process was unsuccessful. Many battered women
use the information at a much later date when they feel strong enough to seek assistance.
80 Iowa Medicine Volume 85/ 2 February 1995
DOMESTIC VIOLENCE ISSUES
Domestic violence center staff must follow Iowa Code Section 236A on confidentiality.
Staff is not allowed to release information regarding any woman with whom they are work-
ing unless they have written permission from the woman to release specific information to
a specific person. This means even after you have referred a woman to a shelter, you may
not receive follow-up information on her whereabouts or safety. This can be frustrating for
referring physicians and for shelter staff. However, it is important to remember that in many
cases confidentiality keeps battered women and children safe while they seek help.
Below are the hotline numbers for domestic abuse projects in counties across Iowa.
Project
Number
Counties served
Adel
800/400-4884
Dallas, Madison
Ames
800/203-3488
Boone, Greene, Hamilton, Hardin, Story
Atlantic
800/696-5123
Adair, Adams, S. Audubon, Cass, Shelby, E. Pottawattamie
Burlington
319/752-4475
Des Moines, Henry, Lee, Louisa
Carroll
800/383-9744
Carroll, Crawford
Cedar Rapids
319/363-2093
Benton, Jones, Linn
Cherokee
800/225-7233
Buena Vista, Cherokee, Ida, Sac
Clinton
319/243-7867
Clinton, Jackson
Council Bluffs
712/328-0266
Harrison, Pottawattamie, Shelby
Creston
515/782-6632
Adair, Adams, Clarke, Decatur, Ringgold, Taylor, Union
Davenport
319/326-9191
Scott, Rock Island (Illinois)
Decorah
800/383-2988
Alamakee, Buchanan, Chickasaw, Clayton, Fayette, Howard, Winneshiek
Des Moines
800/942-0333
Polk
Dubuque
319/588-4016
Clayton, Delaware, Dubuque
Eldora
515/858-2618
Franklin, Grundy, Hardin
Estherville
712/362-4612
Clay, Dickenson, Emmet, Palo Alto
Fort Dodge
515/573-8000
Calhoun, Hamilton, Humbolt, Pocahontas, Webster, Wright
Iowa City
800/373-1043
Cedar, Iowa, Johnson, Washington
Jefferson
515/386-4056
Greene
Keokuk
319/524-4445
Lee, Clark (Missouri), Hancock (Illinois)
Malvern
800/468-7333
Fremont, Mills, Montgomery, Page
Marshalltown
800/779-3512
Jasper, Marshall, Poweshiek, Tama
Mason City
800/479-9071
Cerro Gordo, Floyd, Franklin, Hancock, Kossuth, Mitchell,
Winnebago, Worth
Muscatine
319/263-8080
Muscatine
Ottumwa
800/464-8340
Appanoose, Davis, Jefferson, Keokuk, Lee, Mahaska, Monroe, Van Buren,
Wapello, Wayne
Pella
800/433-7233
Marion, Warren
Sioux Center
800/382-5603
Lyon, O’Brien, Osceola, Plymouth, Sioux
Sioux City
800/982-7233
Woodbury, Monona, Plymouth, parts of Dakota (Nebraska), Union (South Dakota)
Waterloo
319/233-8484
Black Hawk
Waverly
800/410-7233
Bremer, Butler
STATEWIDE DOMESTIC ABUSE HOTLINE
800/942-0333
Iowa Medicine Volume 85 / 2 February 1995 81
Iowa | Medicine
@f you have a
reception area full
of patients, let tier
know you are con-
cerned abut what
she has told you
and ask her to
schedule another
appointment to
discuss it.
Look on page 80 of
this issue for a map of
Iowa domestic abuse
shelters and complete
information on ser-
vices offered locally
around Iowa.
What works, what doesn't
You can accomplish much in a short time — “Educate yourself about this complex prob-
lem and beware of the assumption that most victims of partner battering present in the
emergency room. Even if you have a reception area full of patients, don’t be afraid to ques-
tion a patient about possible abuse. If the woman admits she has been abused, let her know
you are very concerned about what she has told you and ask her to schedule another
appointment so you can discuss it with her. Finally, develop a relationship with the people
in your local community who are trained and equipped to assist victims of domestic vio-
lence. Don’t feel you have to handle the problem alone.” Rebecca Wiese, MD, Davenport
FAMILY PHYSICIAN AND CIIAIR OF THE IOWA MEDICAL SOCIETY’S TASK FORCE ON DOMESTIC VIOLENCE.
Let them know you care — "Patients usually want to tell someone, but they won’t tell
just anyone. They won’t share confidences with someone who appears intolerant or uncar-
ing. The most important thing is to be kind, non-threatening and non-judgmental when you
suspect a patient is living in an abusive situation. It is imperative to let them know you care
and that you will help them if they want help. Patients find it much easier to discuss these
problems if they understand that many other people have been in similar situations and
that there are many people willing to help.” Lee Eagre, MD, Waverly family physician.
Ask and ask again — “Keep an open mind and keep the possibility of abuse in your mind
at all times. Don’t be blinded by a patient’s socioeconomic status. Many of us have a bias
that this doesn’t go on in the upper classes. Don’t be afraid to keep asking. Some women
might admit it the twelfth time you ask. Even then, she may not be ready to seek help.
Remember there are agencies that will he very helpful. Become familiar with the services
offered by your local domestic violence shelter.” John Ankeny, DO, Des Moines emergency
ROOM PHYSICIAN.
A special program for victims — “Each year, the tragedy of domestic violence affects
over five million American women from all socioeconomic, religious and racial back-
grounds. Many abusers attack the victim’s face with their hands, a knife, cigarettes or other
weapons in an effort to retain control and keep other men away. Victims often do not seek
medical assistance for injuries which are not life-threatening such as broken noses, bruis-
es, small lacerations or burns.
“The lack of initial treatment of these injuries can lead to facial disfigurement from scar-
ring and poor healing, as well as deformity from the poorly healed hone injuries. For exam-
ple, a malar tripod fracture, septal hematoma or nasal bone fracture may not be readily
apparent because of overlying swelling or the lack of significant symptoms, so the patient
avoids treatment. Once the swelling resolves and the tissues contract, dramatic deformities
DOMESTIC VIOLENCE ISSUES
may result and may further lovver the victim’s self-esteem.
“Because many victims may not have insurance or finances to pay for correcting this
damage, the American Academy of Facial Plastic and Reconstructive Surgery started the
National Domestic Violence Project. This program provides free consultation and surgery to
victims of domestic violence, thus alleviating some of the pain and psychological injury to
these victims.
“The toll-free project number is 800/842-4546. A call to this number will provide names
of surgeons in the victim’s area who will provide free consultation and perform free surgery
if needed. Perhaps this will help some women break out of the cycle of violence, enhance
their self-esteem and help them rebuild their lives.” Jeffrey Caritiiers, MD, Des Moines
FACIAL PLASTIC SURGEON.
Myths and realities
Myth: Family violence is most prevalent
among the lower class.
Reality: Family violence occurs at all levels
of society and without regard to age, race,
cultural status, education or religion. It may
be less evident among the affluent because
they can find and afford private physicians,
attorneys, counselors and shelters. Individ-
uals with fewer financial resources turn to
more public agencies for help.
Myth: Abused spouses can end the vio-
lence by divorcing the abuser.
Reality: According to the U.S. Department
of Justice, about 75% of all spousal attacks
occur between people who are separated or
divorced. Separation often brings on an
increased level of harrassment and violence.
themselves for the abuse. Friends, family
and service providers reinforce this by lay-
ing blame and the need to change on the
victim’s shoulders.
Myth: Alcohol, stress and mental illness
are major causes of physical and verbal
abuse.
Reality: Abusive people — and even
their victims — often use those conditions
to excuse or minimize the abuse. But,
abuse is a learned behavior not an uncon-
trollable reaction. People are abusive
because they’ve acquired the believe that
violence and aggression are acceptable and
effective responses to real or imagined
threats. Fortunately, abusers can benefit
from counseling.
Myth: The victim can learn to stop doing
things that provoke the violence.
Reality: In a battering relationship, the
abuser needs no provocation to become vio-
lent. Violence is the abuser’s pattern of
behavior and the victim can’t learn how to
control it. Even so, many victims blame
Myth: Being pregnant protects a woman
from battering.
Reality: Battering frequently begins or
escalates during pregnancy. Dul
About 75% of all
spousal attacks
occur between
people who are
separated or
divorced.
Physician survey
If you haven’t already
done so, please com-
plete the physician
survey on domestic
violence which
appeared in last
month’s Iowa
Medicine and return
it to IMS headquarters.
This survey will help us
determine future
educational efforts. If
you misplaced your
survey, call Bev Corron
at the IMS, 800/747-
3070 for another copy.
Iowa Medicine Volume 85 / 2 February' 1995 83
Medical Protective Policyowners
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no strings attached! In an era of frivolous suits, changing government attitudes about the
confidentiality of the National Practitioner's Data Bank and increased scrutiny by credentialing
committees, shouldn't you have The Medical Protective Company as your professional liability
insurer? Call your local General Agent for more information about how you can have more control
in defense of your professional reputation.
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Iowa 1 Medicine
SCIENCE AND EDUCATION
The Journal
of the Iowa Medical So c i e t y
Iowa domestic abuse scenarios
# Lee Fag re , MD; Kathleen Buckwalter, RX
Editor’s note: The following cases are in
response to a request by the Iowa Medical
Society’s Domestic Violence Task Force for
domestic violence scenarios. Cases 1 , 2 and
3 were submitted by Dr. Lee Eagre. Case 4
was submitted by Kathleen Buckwalter.
Casel
A 26-year-old G3PlSAbl married white
female normally eared for by one of your
partners presents with diffuse abdominal
pain not associated with cramping, vaginal
discharge or bleeding. Opening her chart you
note she is 20 weeks pregnant and had an
uneventful pregnancy up until one month ago
when she was seen in the emergency room
with similar symptoms. Findings were nega-
tive and her tenderness disappeared over the
next two weeks. The patient is very con-
cerned she is going to lose the baby like she
did during her last pregnancy. Physical exam
reveals a diffuse tenderness over the
abdomen with a soft uterus and fetal heart
tones which are reassuring at 152bpm. The
sterile speculum exam reveals a closed os
with no bleeding or rupture of membranes.
You should next:
1) Assure her everything is okay, send her
home and have her come back to see her
regular doctor tomorrow.
2) Order an ultrasound to rule out abruptio.
3) Set her up for a non-stress test.
4) Ask her questions from your domestic
violence screening questionaire.
While there are no specific right answers
there are a few wrong answers. The patient is
only 20 weeks and is not far enough along for
a non-stress test. Reassuring her everything
is okay should be done as well as an ultra-
sound at some point. However one of the first
things the physician should do is clarify
whether this is a domestic violence situation
and make sure the mother is safe from future
harm. Family stressors are at a high level
during pregnancy and it is a common time
for violent situations to arise.
Case 2
A 35-year-old married white female pre-
sents to the emergency room late one night
with alcohol on her breath and a painful right
jaw. Her husband brought her in and hovers
at her bedside listening closely to your
exchange with his wife. She states she fell
down the stairs to the basement and can’t
open her jaw. Physical exam reveals a contu-
sion over the right mandible with tenderness
at the TMJ. The patient is unable to open her
jaw more than a centimeter and has a maloc-
clusion when asked to bite.
You should next:
1) Ask her questions from your domestic
violence questionaire while she is in the
emergency room.
2) Get x-rays of her jaw.
3) Call in a social worker because you sus-
pect domestic violence.
4) Call the police saying you suspect domes-
tic violence and you’re not sure what the
husband will do when/if he is confronted.
5) Follow the patient to x-ray and ask your
domestic violence questions at that time.
The presence of the husband in the emer-
gency room makes questioning the patient
difficult. Concern for a potentially violent sit-
uation should make the physician request
the presence of the police in the emergency
room. A good way to separate the husband
and wife is to take her back to x-ray and ask
her questions at that time. In this case the
The IMS
Education Fund
has designated
th is article as
the Henry Albert
Scientific
Presentation
Award for
February 1995.
Lee Fagre, MD
Dr. Fagre is a family
practitioner in Waverly.
Kathleen
Buckwalter, RX
Ms. Buck-waiter is a
professor at the College of
Nursing, University of
Iowa, Iowa City.
Iowa Medicine Volu me 85 / 2 Febmary 1995 85
Iowa domestic abuse scenarios
continued
patient confided that her husband had beaten
her, but she refused to file charges and
refused any counseling with a crisis worker.
Had this happened now instead of five years
ago the physician could contact the local law
enforcement agency. A no contact order
could be issued regardless of whether or not
the patient files charges if the physician and
the judge deem the patient is in danger.
Case 3
A 28-year-old married female who works
on your office clerical staff comes in Monday
morning with a black eye. She states she and
her husband, who is a well respected young
business man, were at a football game over
the weekend where a drunken spectator
elbowed her in the eye. You check her over
and pronounce her fine, but you notice she
needs a tetanus. On pulling up the sleeve to
give her a Td you see several ecchymosis on
her upper arm in the shape of a hand grasp-
ing the arm and squeezing.
You should next:
1 ) Accuse her of lying and tell her to come
out with the truth.
2) Give her the Td injection, note your
findings in her chart for future refer-
ence and ask her to set up a complete
physical tomorrow.
3) Check some blood clotting studies.
4) Ask her to come to your office and
question her about domestic violence.
In this case, which happened several years
ago, other office staff had known her husband
had been beating her, but were unable to
convince her to do anything about it. The
topic was even more taboo at the time of this
case than it is now and it was only with time
and several attempts at intervention that we
were able to convince her she was not at
fault.
Case 4
Mr. Smith is a 70-year-old man suffering
from Alzheimer’s disease who has been cared
for by his wife for 10 years. One day while
their seven-year-old granddaughter was visit-
ing, Mr. Smith suddenly and without warning,
approached his granddaughter from behind
and hit her in the back with his fist. When
Mrs. Smith heard of her husband’s unpro-
voked behavior she slapped him across the
face as hard as she could. She confided this
incident to Dr. Marcus Welby when she
accompanied her husband for an examina-
tion. Mrs. Smith continued by saying “You
can report me if you want. I wanted him to
know just exactly how my granddaughter felt
when he hit her. My husband always hits
those who are weaker than himself. You
wouldn’t believe what I’ve had to put up with
during our marriage.”
You should next (choose as many as you
like):
1 ) Explore Airs. Smith’s statements — “Aly
husband always hits those who are
weaker than himself. You wouldn’t
believe what I’ve had to put up with
during our marriage.”
2) Refer Mrs. Smith to a licensed psychol-
ogist for therapy.
3) Recommend placement for Air. Smith in
a long-term care facility.
4) Report Mrs. Smith for dependent adult
abuse.
5) Provide information on community
resources and agencies (e.g., Alzheimer’s
support group, adult day care center).
6) Provide instruction in behavior man-
agement for persons with Alzheimer’s
disease.
This may have been Mrs. Smith’s attempt
at asking for help. Dr. Welby explored the sit-
uation further. This was the first time Mrs.
Smith hit her husband. She felt he had been
manipulative throughout their marriage and
although had been a “good provider,” he had
difficulty expressing love. He had never phys-
ically abused her, but had been “mean” to
their two sons and occasionally hit them.
Despite these circumstances, Airs. Smith
expressed affection for her husband and
wanted to continue to care for him in their
home. Dr. Welby provided instruction in
behavior management and gave Mrs. Smith a
list of community resources. Mrs. Smith
began attending an Alzheimer’s support
group and utilizing an adult day care center
which allowed her more time for recreational
activities. The next time Dr. Welby visited
Airs. Smith she expressed more confidence in
her caregiving role and a greater satisfaction
with her life in general. El
SCIENCE AND EDUCATION
Laparoscopic splenectomy
% Warren Bower, MD; David Coster, MD: Victor Wilson, MD; Mare Westberg, MD
The application of laparoscopic techniques to
general surgical procedures has revolution-
ized modern surgical care. With continued
advancement in instrumentation, the majori-
ty of common surgical procedures will he
done with minimally invasive techniques.
There is already widespread application in
gynecologic, biliary, urologic and gastroin-
testinal surgery for procedures such as pelvic
exploration, uterine myomectomy, ovarian
cystectomy, cholecystectomy, common bile
duct exploration and stone removal, pelvic
node dissection and appendectomy.
Other procedures are being done as well
but are less widespread. These include va-
gotomy, pyloroplasty, Nissen fundoplication,
colon and small intestine resection, nephrec-
tomy, adrenalectomy and others.
The benefits of decreased recovery time,
less pain, decreased cost, shorter hospitaliza-
tion times, fewer medication requirements
and increased patient satisfaction are obvious
for some procedures, less so for others. We
applied advanced laparoscopic techniques for
the removal of the spleen, a procedure not
commonly done laparoscopically, with excel-
lent outcome.
Case Report
A 40-year-old white female was referred for
idiopathic thrombocytopenic purpura (ITP)
with failure to respond to medical treatment
with prednisone. Her initial platelet count was
38,000 when first diagnosed. Her complaint
was an upper respiratory infection and easy
bruising. Her health was otherwise marred
only by hypertension, for which she took
hydrochlorothiazide and Tenoretic® (atenolol
and chlorthalidone). Her physical examina-
tion, aside from multiple bruises and moder-
ate obesity, was unremarkable. She had good
response to initial treatment, with platelet
count rising to normal with prednisone thera-
py. However, once her prednisone was
tapered to a dosage of 20mg per day, her
platelet count dropped to 2000 and she devel-
oped spontaneous bruising again. Her pred-
nisone was increased to 60mg per day with a
return of the platelet count to 238,000 and
she was scheduled for splenectomy.
After routine, electrocardiogram, chest x-
ray, blood chemistries, complete physical for
medical clearance, and intramuscular Pneu-
movax, the patient was prepared for surgery.
There she was given a general anesthetic and
placed in a supine position with the legs apart,
thighs level with the abdomen. A nasogastric
tube and foley catheter were placed. Six trocar
sites were selected, and all trocars were insert-
ed under direct vision after the abdomen had
been insufflated with G02 (Figure 1 ).
The patient was placed in extreme reverse
trendelenberg and rotated to the right. The
stomach was retracted to the right with a
Babcock clamp and the spleen was identified.
The splenocolic ligament was divided and the
lower pole of the spleen mobilized. The short
gastric vessels were then identified, clipped
and divided, progressing cephalad until all
were freed. The superior peritoneal attach-
Figure 1. Port placement for the six trocar
technique of laparoscopic splenectomy.
Warren Bower, MD
Dam D Coster, MD
Victor Wilson, MD
Mark Westberg, MD
Drs. Bower, Cosier and
Wilson are general
surgeons practicing as
Surgical Associates in
Grinnell. Dr. Westberg is
a hematologist/oncologist
at Iowa Methodist
Medical Center, Des
Moines.
Iowa Medicine Volume 85 / 2 February 1995 87
Iowa : Medicine
SCIENCE AND EDUCflTIO N
Laparoscopic splenectomy
continued
ments to the spleen were divided and the
spleen was free on its pedicle. We placed an
Endo-GIA stapler with a vascular cartridge
across the splenic hilum to divide the spleen
completely from its main blood supply. It was
placed in a plastic bag and brought out
through a slight enlargement of the trocar
site in the left lower quadrant. The entire
procedure took less than two hours.
The patient had a nasogastric tube in place
for 24 hours, was placed on full liquids and
advanced to a regular diet by the following
day. Pain was minimal. She was discharged
from the hospital 48 hours after surgery with
a normal platelet count on a tapering dose of
prednisone. She returned to normal activity
within 10 days.
identified and are easily avoided with proper
technique. The laparoscopic splenectomy
can be done safely and has the added advan-
tages of decreased length of hospital stay,
less patient discomfort, earlier return to reg-
ular activity and decreased cost. It is applica-
ble to most patients who require splenecto-
my for the usual medical indications.
It probably is not appropriate or feasible
for splenomegaly due to the technical limita-
tions caused by the size of the spleen and it
is unlikely to be useful in unstable trauma
patients. Those two exceptions aside, this
new approach to splenectomy is likely to
become the gold standard of the future.
References
Discussion
Laparoscopic splenectomy has been per-
formed successfully for staging of Hodgkins
disease, ITP, Hereditary Spherocytosis and
warm antibody hemolytic anemia.1 1 The pit-
falls of the laparoscopic technique have been
I Thibault, C, at al: Laparoscopic splenectomy:
operative technique and preliminary report. Surg Lap
Endo 1992;2:248-53.
2. Delain e, B and Maignien, B: Laparoscopic splenec-
tomy-technical aspects. Surg Endo 1992;6:305-8.
3. Carroll, BJ: et al: Laproscopie splenectomy. Surg
Endo 1992;6:183-85. D31
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88 Iowa Medicine Volume 85 / 2 February' 1995
Iowa [Medicine
THE EDITOR COMMENTS
Family life can
be beautiful
Domestic violence is the major topic again
in this issue of Iowa Medicine. It is
unfortunate because happiness and love
will bind a family with everlasting ties that
carry through adversity as well as with the
pleasant times. Cultural characteristics often
are denominators in the relationships between
family members. Familial examples and expe-
riences may enter into the patterns of violence.
If the cultural mores of a family “dictate” a
major dominance of male over female, violence
appears “accepted” without moral or legal re-
course. But, such should not be.
The peoples of the United States are of di-
verse origins. The “melting-pot” of cultures
within our society presents different attitudes
as well as language. I have a concern about that.
Our governmental bodies seem
bent on providing multilingual en-
vironments. Non-English speaking
children are to be taught in their
native language; documents are to
be prepared in various languages.
Past generations of immigrants who
became part of our society found it
necessary to learn the English lan-
guage. Their mother tongue was reserved for
their home, family and acquaintances of the
same culture.
Based on the premise that we must preserve
the mother tongue in their new country, are we
to preserve their family behavior also? If strong
paternal dominance with violent overt behav-
ior is acceptable in their country of origin, are
we to accept such here?
Violence has been a part of human behavior
from centuries past: political violence, reli-
gious violence, as well as narrow and broad
social violence. There are always the dominant
and the oppressed. Yet, in recent years there
has been an increase in known domestic vio-
lence. Is this a true increase or a reflection of
recognition of the obvious?
As 1 compose these comments for publica-
tion, I reflect upon my own experiences. I come
from a pure German background. My grand-
parents used the English language in public;
German in the home. My parents were as fluent
in Plattdeutsch as in English. They assimilated
into the ways of life in Nebraska. Though there
was paternal dominance in my family, there
was no violence.
My parents celebrated over 50
years of marriage. On Christmas
Day, Jeannette and I celebrated
our golden wedding anniversary
and they have been golden years.
Sure, there have been difficult
times, but the happy days with
four children and their families
with eight grandchildren have been
a blessing. Life is too dear, sacred and beautiful
to be blemished with domestic violence. Why
do humans have such a difficult time learning
the beauty to be found in tranquility? Let us
hope the future has more peace, love and hap-
piness. Wouldn’t that be great! OH
Though there
was paternal
dominance in
my family,
there was
no violence.
Marion Alberts, MD
Iowa Medicine Volume 85/ 2 Februa>-\' 1995 89
9S
The Throckmorton Surgical Society
Spring Meeting
IOWA METHODIST
MEDICAL CENTER
Surgical Symposium on
CONTROVERSIES IN SURGERY
AN IOWA HEALTH SYSTEM AFFILIATE
April 21-22, 1995
Iowa Methodist Medical Center • Jester Auditorium
Des Moines, Iowa
SURGICAL I
SOCIETY |>
y
Blake Cady, M.D.
Professor of Surgery
Harvard Medical School
Boston, Massachusetts
Guest Faculty
Maureen Martin, M.D.
Associate Professor of Surgery
Director of Organ Transplantation
University of Iowa
Iowa City, Iowa
John H. Ranson, M.D.
Professor of Surgery
New York University Medical School
New York, New York
Richard M. Devine, M.D.
Assistant Professor of Surgery
Department of Colon/Rectal Surgery
Mayo Clinic School of Medicine
Rochester, Minnesota
Jon A. vanHeerden, M.D.
Professor of Surgery
Mayo Clinic School of Medicine
Rochester, Minnesota
Topics
“Management of Metastatic Liver Disease”
“Diagnosis and Treatment of Primary Hyperparathyroidism”
“Current Evaluation and Treatment of Acute Pancreatitis”
“Diagnosis and Management of Post-Cholecystectomy Injuries”
“Hypercortisolism — What the Surgeon Should Know”
“Role of Axillary Dissection in Early Breast Cancer”
“Evaluation of Thyroid Nodules”
“Timing of Surgery in Gallstone Pancreatitis”
“In Situ Breast Cancer — the Role of Radiotherapy”
“Role of Preoperative Radiation Treatment in Rectal Cancer”
“Laparoscopic Colectomy”
Accreditation
As an organization accredited for Continuing
Medical Education, the Iowa Methodist Medical
Center certifies that this offering meets the
criteria for Category I credit toward AMA
Physician’s Recognition Award, provided it is
used and completed as designed:
Friday, April 21, 1995 7 hours
Saturday, April 22, 1995 3 hours
Cost
Physician fee $150.00
Resident fee $ 35.00
Contact
Department of Surgery Education
Iowa Methodist Medical Center
1221 Pleasant Street, Suite 550
Des Moines, Iowa 50309; 515/241-4076
Fax: 515/241-4080
Iowa [Medicine
PHYSICIAN LEARNER
The continuum of
medical education
Milestones in medical education are fa-
miliar to all physicians. The first mile-
stone is acceptance into medical school.
Other milestones follow in sequence: comple-
tion of the preclinical coursework; clerkships;
graduation; graduate residency training;
licensure; and the initiation of practice.
Although it is logical to consider each of
these milestones as a distinct event, the mile-
stones are not discontinuous. They represent
points in time in the continuum of medical
education.
What may be discontinuous about this pro-
cess is that there is a perception that medical
education is linear and not circular.
With a linear perception we view medical
education as an aging process. The young and
uninitiated ( medical students) gain knowledge,
acquire judgement and skills (es-
pecially as residents) then apply
their education in the community
(as practitioners). The practice of
medicine, fortified by continuing
education, proceeds through the
lifetime of the physician.
It is obvious to most physicians,
however, that their abilities, espe-
cially the integration of knowledge and skill
with experience, continue to develop long after
the milestone of residency has transpired. The
mid-career physician should be at the peak of
professional competence.
Our educational institutions rely on these
phenomena to educate the next generation of
physicians. The ignorant and inexperienced
are matched with the knowledgeable and wise.
The educational process acquires a circular
continuum, the mid-career physician educat-
ing the neophyte student who eventually repli-
cates the process with the next generation of
students.
Of course the educational dynamic does not
require the separation of teacher and student to
be measured in decades. The second year
medical student is often the tutor of the first
year student; the resident is the counselor for
the student.
An expanding challenge awaits educators as
the emphasis in medical education now moves
toward ambulatory education in the primary
care disciplines.
Of necessity a larger portion of this educa-
tion will occur in community settings where
primary medical care is provided. The cadre of
physician-educators will be ex-
panded, drawing on the interest
and experience of community phy-
sicians.
There is no more powerful mo-
tivator to the experienced physi-
cian to remain current than an
inquisition by a youthful student.
The circle becomes complete. El
There is a
perception that
medical educa-
tion is linear
and not circular.
Richard Nelson , A/D
Iowa Medicine Volume 85 / 2 February 1995 91
Iowa [Medicine
Classified Advertising
Emergency Medicine
Ottumwa, Iowa
Exceptional opportunity for primary care trained
or experienced emergency physician. Ottumwa
Regional Health Center is a 275-bed facility
serving an 8 county area in SE Iowa and NE
Missouri. 21, 000 volume/1 2 and 16 hour shifts
with double coverage at peak times. Excellent
medical backup is provided by a medical staff
of 50 physicians representing a broad range of
specialties. Rathbun Lake, a beautiful 1 1,000
acre lake, is 40 miles from Ottumwa and offers
an abundance of recreational activities. Mid-
western hospitality, safe living and award win-
ning schools make Ottumwa a place to call
"home." Guaranteed minimum compensation
package including paid malpractice. Send CV
or call Sheila Jorgensen, Emergency Prac-
tice Associates, P.O. Box 1260, Waterloo,
Iowa 50704; 800/458-5003.
Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: family
practice, invasive cardiology, oncology/
hematology, orthopedic surgery and general
internal medicine practice. The Mankato
Clinic is a 65-doctor multispecialty group
practice in south central Minnesota with a
trade area population of +250,000. Guaran-
teed salary first year, incentive thereafter with
full range of benefits and liberal time off. For
more information, call Roger Greenwald,
Executive Vice President, at 507/389-8500 or
Anthony C. Jaspers, President, at 507/726-
2136 or write 1230 East Main Street, P.O. Box
8674, Mankato, Minnesota 56002-8674.
Marshalltown , Iowa
Best of both worlds — rural small group at-
mosphere, urban large group amenities. Seek-
ing quality emergency physicians interested
in stellar emergency medicine practice. Full-
time and regular part-time. 1 2K volume /12-
hour shifts. Democratic group, highly com-
petitive compensation, paid St. Paul mal-
practice with unlimited tail, excellent benefit
package/bonuses for full-time. Numerous
other Iowa locales. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021; 800/729-
7813 or 515/964-2772.
General Surgeon, Creston, Iowa — An opening
for a third BC/BE surgeon in a very busy
general surgery practice located 1 hour from
Des Moines, Iowa. Two-surgeon department,
expanding to 3 due to work load, is associated
with 13 other physicians. Salary and benefit
package very lucrative including moving
expenses and full partnership within 1 to 2
years with limited call duty. Country living in
a community of 9,000 with excellent educa-
tional system, recreation, low crime rate and
lifestyle not found in metro areas. Contact
Mike Brentnall, 515/782-2131 or send CV to
Creston Medical Clinic, PC, 526 New York
Avenue, Creston, Iowa 50801.
Locum Tenens
Emergency Medicine
Seeking quality physicians interested in
emergency medicine practice or primary
care locum tenens. Full-time and regu-
lar part-time. Numerous Iowa locales.
Democratic group, highly competitive
compensation, paid St. Paul malprac-
tice with unlimited tail, excellent ben-
efit package/bonuses to full-time phy-
sicians. Contact ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021.
Phone 1-800/729-7813 or 515/964-2772.
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
of Des Moines. We have a beautiful new
facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
General Faculty, Department of Family
Practice, University of Iowa College of
Medicine — The University of Iowa Department
of Family Practice offers full-time faculty
positions for residency-trained, ABFP certified
family physicians. Obstetric skills and
previous teaching experience highly desirable.
Additional faculty needed to address new
primary care initiatives. As a part of a full
academic department, responsibilities include
teaching, research and patient care. Well-
established, 24-resident program is university-
administered, community-based, and has
admissions at community and university
hospitals. A new model office facility is being
built. Well-established department with
special strengths in its clinical and behavioral
science faculty. As a “Big Ten” university
community, Iowa City is a great place to live.
Appointment and salary commensurate with
qualifications and experience. The University
of Iowa is an Equal Opportunity and Affirma-
tive Action employer. Women and minorities
arc strongly encouraged to apply. Submit a
letter of interest and CV to Gerald .1. Jogerst,
MD, Interim Department Head, Department of
Family Practice, 2149 Steindler Building, Iowa
City, Iowa 52242-1097; 319/335-8454.
No Assembly Lines Here — FPs, IMs and OB/
GYNs at North Memorial-owned and affiliated
clinics don’t hand patients off to the next
available specialist. Guide your patients
through their entire care process at one of our
25 practices in urban or semi-rural Minneapo-
lis locations. Plus, become eligible for 815,000
on start date. Interested BC/BE MDs, call 1/
800-275-4790 or fax CV to 612/520-1564.
Family Practice
Northeast Iowa
Seeking quality primary care physician
interested in family practice locum tenens
opportunity with potential for full-time
appointment. Monday through Friday 9
a.m. to 5 p.m. Shared town call. No OB.
Highly competitive compensation. Paid
St. Paul malpractice with unlimited tail.
Excellent benefit package/bonuses. Please
contact Melissa Milliken, ACUTE CARE,
INC., PO Box 515, Ankeny, Iowa 50021.
Phone 800/729-7813 or 515/964-2772.
92 Iowa Medicine Volume 85/ 2 February 1^95
CLASSIFIED ADVERTISING
Emergency Medicine
Fort Dodge, Iowa
Immediate opportunity for primary care
trained or experienced emergency physi-
cian. Trinity Regional Hospital is a 200-bed
facility acting as a regional referral center for
northwest Iowa. 15,000 annual volume/24-
hour shifts. Medical backup is diverse with a
full range of specialists represented. Ft.
Dodge, a community of 26,000 nested in the
beautiful Des Moines River valley, is the
commercial hub of north central Iowa. Ft.
Dodge provides a warm friendly community
in which to live and raise a family. An
outstanding compensation package includes
health/dental, life, disability, malpractice in-
surances. Send CV orcall Sheila Jorgensen,
Emergency Practice Associates, P.O. Box
1 260, Waterloo, Iowa 50704; 800/458-5003.
Primary Care Physicians and Subspecialists —
Are being sought for a variety of group
practices located throughout the upper
Midwest and New York state. Choose from
metropolitan cities, college towns, popular
resort communities or traditional rural
distinctions. This month, opportunities
available for physicians specializing in family
practice, internal medicine, pediatrics,
occupational medicine, hematology/oncology
and nephrology. New opportunities monthly!
For all of the facts, call 800/243-4353 or write
to Streleheek and Associates, 10624 North
Port Washington Road, Mequon, Wisconsin
53092.
Minneapolis, MN — Opportunities available for
BE/BC family practitioners with OB to join 6
person group. Western Minneapolis suburb.
No practice buy-in required. Excellent salary
and benefits. Please send CV or call Nancy
Borgstrom, Aspen Medical Group, 1021
Bandana Boulevard East #200, St. Paul,
Minnesota 55108, 612/642-2779 or fax 612/
642-9441. EOE.
Boone , Iowa
Seeking a quality emergency physician
interested in a stellar emergency medi-
cine practice. Full and regular part-
time position available. Democratic
group, paid St. Paul malpractice with
unlimited tail. Excellent benefit pack-
age/bonuses to full-time physicians.
Average volume with above-average
compensation. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021;
phone 800/729-7813.
Internal Medicine, Carroll, Iowa — Outstand-
ing professional opportunity for an internal
medicine physician in a progressive, safe and
clean community of 10,000. This opportunity
is available for either practicing internal
medicine physician, or the internal medicine
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more informtion, call Randy Simmons, vice
president, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
LeMars , Iowa
Seeking quality physicians to prac-
tice at a 4300 average volume ER.
Director and staff positions. Full
and regular part-time. Democratic
group, highly competitive compen-
sation, paid St. Paul malpractice with
unlimited tail, excellent benefit pack-
age/bonuses to full-time physicians.
ACUTE CARE, INC., P.O. Box 515,
Ankeny, Iowa 50021; phone 800/
729-7813.
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Emergency Medicine, Council Bluffs, Iowa —
Opening available for qualified physician to
join group of emergency physicians. Training
and/or certification in primary care specialty
or emergency medicine. Flexible scheduling.
Newly remodeled emergency department.
Enjoy rural and urban atmosphere. Compen-
sation up to +jS200K/year plus vacation. Write
Bluffs Emergency Care Services, PC, 933 East
Pierce Street, Council Bluffs, Iowa 51503; 712/
328-6111.
Emergency Medicine
Clinton, Iowa
Outstanding opportunity in emergency
medicine for primary care trained or
experienced emergency physicians.
Samaritan Health Systems is a 275-
bed hospital located in Clinton, Iowa.
1 4,000 annual volume/1 2-hour shifts.
Samaritan Health Systems medical
staff consists of 70 physicians repre-
senting a comprehensive range of
medical/surgical specialties. This Mis-
sissippi riverfront community offers a
variety of leisure activities, affordable
housing and top-notch schools. An
outstanding compensation package in-
cludes guaranteed minimum compen-
sation, and health/dental, life, disabil-
ity, malpractice insurances. Send CV
or call Sheila Jorgensen, Emer-
gency Practice Associates, P.O. Box
1260, Waterloo, Iowa 50704; 800/
458-5003.
Family Practice, Carroll. Iowa — Outstanding
professional opportunity for family practice
physicians in a progressive, safe and clean
community of 10,000. These opportunities
are available for either experienced family
practice physicians, or the family practice
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more information, call Randy Simmons, Vice
President, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll. Iowa 51401.
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for 82.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for $25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine
Volume 85/ 2 February 1995 93
Iowa [Medicine
CLASSIFIED ADVERTISING
Sioux City — An excellent position is available
for a BC/BE family practice physician in a new
community health center. A full range of
family practice medicine is needed in a
community that is very supportive of the
center. Sioux City is a great place to raise a
family and has excellent public and parochial
school systems, a community college, 2 liberal
arts colleges, a graduate center, 2 excellent
medical centers, a Residency Training
Program (family practice), etc. The center
offers a competitive compensation and benefit
package, paid malpractice, etc. FEDERAL
LOAN REPAYMENT PROGRAM AVAILABLE.
For more information write Jeff Hackett,
Executive Director, Siouxland Community
Health Center, 1709 Pierce Street, Sioux City,
Iowa 51105 or call 712/252-2477.
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Not Just .Another Recruitment Ad — Opportu-
nities at North Memorial-owned and affiliated
clinics will give you a shot of adrenaline
because we practice in a care management
environment that FPs, IMs and OB/GYNs
thrive on. Guide your patients through their
entire care process at one of our 25 clinics in
urban or semi-rural Minneapolis locations.
Plus, become eligible for $15,000 on start date.
Interested BC/BE MDs, call 1/800-275-4790 or
fax CV to 612/520-1564.
Urgent Care
Davenport, Iowa
Seeking BC/BE family practice physicians to
practice in urgent care center. Full or regular
part-time. Highly competitive compensation
paid with generous benefits.
Send or fax CV to:
HSMMCo.
2535 Maplecrest Dr., Suite 23
Bettendorf, Iowa 52722
319/344-3621; 319/344-3632 (fax)
Monroe is
Madison* # Milwaukee
1 * MONROE
Dubuque*
^Chicago*!
Ranked 23rd in 100 Best
Small Towns in America,
Monroe, Wisconsin,
boasts a strong economy,
year-round outdoor ac-
tivities, a comprehensive
and diverse school system, and many amenities for an excellent quality of life.
Madison, Wl, Dubuque, IA, and Rockford, IL, are just an hour away, while
Chicago and Milwaukee are within an easy two-hour drive. When you’re think-
ing about a setting for your professional practice and the “good life” for your
family, give some thought to Monroe.
Our town of 10,000 is home to The Monroe Clinic, the hub of healthcare in
Monroe. A consolidated and integrated healthcare facility including a 140-bed
acute care hospital with 24-hour ER coverage and an adjoining 1 14,000 sq. ft.
state-of-the-art clinic, The Monroe Clinic provides a full range of diagnostic
and therapeutic testing and treatment. We invite your participation in our 50+
physician multispecialty group practice as a BC/BE physician in: FAMILY
PRACTICE, OB/GYN, CARDIOLOGY (non-invasive), OUTPATIENT
PSYCHIATRY, GENERAL SURGERY, ORTHOPEDIC SURGERY,
PULMONOLOGY, AND DERMATOLOGY.
We offer productivity based pay with excellent 1st year income guarantee, free-
dom from office management and buy-in costs, and comprehensive benefits
including $3750 CME allowance. For more information, write or call: Physi-
cian Staffing Specialist, THE MONROE CLINIC, 515 22nd Ave., Monroe,
WI 53566. 800-373-2564. Or fax resume to: 608/328-8269. EOE.
The Monroe Clinic
A proud caring tradition
94 Iowa Medicine Volume 85 / 2 February 1995
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Iowa 1 Medicine
Professional Listing
Allergy
Emergency Medicine
John A. Caffrey, MD, 1»C
1212 Pleasant, Suite 106
lies Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, I’C
A.Y. Al-Shash, Ml)
R.K. Agarwal, MD
1701 22ntl Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljko K. Zivkovieh, MD
Robert A. Column, Ml)
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency '
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 5002 1
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Robert .!. Rarrv, Ml)
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Mligard, MD, FAAD
James I). Hunker, MD, FiUI)
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Rrage, MD
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Med icine
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gervieh, MI)
Daniel .1. Nchrocdcr, Ml)
Ravi K. Vemuri, Ml)
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Internal Medicine
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MD, ABIM
Grace Z. Ang, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MI)
Laurence S. krain, Ml)
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology', EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
Janies R. Lamorgcsc, MD
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
llosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery'
96 Iowa Medicine Volume 85 / 2 February 1995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Haync, MD
Thomas A. Carlstrom, MD
David J. Roarini, MD
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MD
S. Randy Winston, MD
Douglas R. boon tz, MD
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery >
Chad l>. Abcrnathcy, Ml>
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery >
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, Ml)
John M. Gracthcr, MD
Gilbert W. Harris, MD
Janies A. Davison, Ml)
Norman F. Woodlief, MD
Eric W. Bligard, MI)
David I). Saggau, MD
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert I). Whinery, MD
Stephen II. Wollten, Ml)
Robert B. Goffstein, MD
Lyse S. Strnad, MD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Miehael L. Long, MI)
Bradley L. Isaak, MD
Randall S. Brenton, Ml)
James L. Duminctt, MI)
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51 101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Otolaryngology
Iowa ENT, PC
Thomas A. Ericson, MD
Marshall C. Grciman, Ml)
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MI)
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella , Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Lakeview
Medical Park-West Des Moines
Wolfe Clinic, PC
Miehael W. Ilill, Ml)
Daniel J. Blum, M1)
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Iowa Orthopaedic Center, PC
Marvin II. Dubansky, MI)
Marshall Flapan, MD
Sinesio Misol, MD
Joshua D. kimclman, DO
Timothy G. Kenney, MI)
Lynn M. Liiidaman, Ml)
Jeffrey M. Farber, MD
Kyle S. Guiles, Ml)
Scott A. Meyer, MD
Cassini M. Igrant, MD
Donna J. Buhls, MD
Jill R. Meilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85 / 2 February 1995 97
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MD
Kill* cue Peterson, MD
Richard B. Merrick, MI)
Peter V. Bosen, MD
Robert R. Updegraff, MI)
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-IIcad & Neck
Surgery', PC
Thomas .1. Benda, Sr., MI)
James W. White, MI)
Craig C. Ilerthcr, MD
Thomas J. Benda, Jr., Ml)
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MI)
Guy E. McFarland, Ml)
Thomas F. Viner, MD
Douglas E. Dawson, Ml)
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery >,
Facial Plastic Surgery > and Head and
Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. EaMorgcsc, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, ESW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology'
Perinatology
Des Moines Perinatal Center, PC
Neil T. Mandsagcr, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
M a temal-Fetal Me d icine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MD
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matysik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary Diseases
Surgery
Wendell Downing, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice D. Sclincll, MD
Eareeduddin Ahmed, MI)
Arthur B. Scarle, MI)
Bogdan E. Krysztofiak, MD
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Rehabilitation Medicine Associates
William I). dcGravellcs, Jr., MD
Charles E. Denhart, MD
Marvin M. Hurd, MI)
William C. Koenig, Jr., MD
Karen Kienker, MD
Todd C. Troll, MD
Lori A. Sapp, MD
Younker Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, ECCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Advertising Index
Bemie Lowe & Associates 54
Blue Cross Blue Shield 56
Bud Mulcahy's Jeep/Eagle 99
Dale Clark Prosthetics 50
IMS Services 95
Josephs 69
Medieal Protective Company 84
Medical Records
Assistance Services 65
MMIC 100
Monroe Clinic 94
Throckmorton Surgical Society 90
U.S. Air Force 88
98 Iowa Medicine Volume 85 / 2 February 7995
Iowa [Medicine
THE PRESIDENT COMMENTS
Exciting times
These are exciting times. Communities are
pursuing dramatically different ways of
providing health care. In my own commu-
nity, the revolution actually began in the late
1980s and what happened here demonstrates
the forces of change working to reshape our
practices.
Labor and management were on the down-
hill course in Dubuque and two work stoppages
were in effect. A poll of the two sides indicated
health care and health care costs were at the
top of both group’s concerns. The Tri-State
Health CARE Coalition was formed in 1991 by
a labor-management coalition to try and find a
basis for cooperation. Two physicians were
among the early participants. The mission of
this group has changed since the beginning, but
meetings are still held about once
a month. The group’s purpose has
become preparing for the future of
health care.
The Tri-State Health CARE coa-
lition received a grant to establish
a health care vision for the Tri-
State area and explore the feasibil-
ity of a health care purchasing
cooperative. The Coalition’s revised vision
statement clearly demonstrates the group’s
pledge to be a force for change: “The Tri-State
Health CARE Coalition and its stockholders
will use partnership approaches to fundamen-
tally transform the region’s medical care deliv-
ery/financing system from todays fragmented,
costly, acute care oriented, responsibility shift-
ing arrangements to a system founded on af-
fordable area wide coverage for all citizens who
self assume responsibilities, and most impor-
tantly where health — not illness — is the norm!
The mission of the organization is to be the lead
organization in attaining the region’s vision.”
There is a noticeable shift in the way health
care is paid for. The emphasis is moving toward
wage increases for employees instead of health
care benefits. The idea is to get people more
involved in their own care and get them think-
ing about leading healthy lifestyles.
The idea for health insurance purchasing
cooperatives came about because small em-
ployers are having difficulty obtaining afford-
able coverage for employees. The Iowa Legisla-
ture has created guidelines for buyers of health
care services to organize to negotiate price and
quality with sellers of health care
benefits. Sellers may be insurers,
managed care organizations or
other structures including physi-
cian organizations.
The Dubuque Coalition has stud-
ied a Rockford, Illinois plan
whereby a group of companies hire
local physicians to provide all pri-
mary care for their employees and specialty
care is paid under traditional medical plans. A
national program, Healthy 2000 has been initi-
ated in Dubuque through the CARE coalition.
The Tri-State Health CARE coalition is meeting
now with provider groups every two weeks.
As 1 said, these are exciting times. Have you
looked to see if you should be taking part? QiU
The emphasis
is moving
toward wage
increases
instead of health
care benefits.
James White, MD
Iowa Medicine Volume 85 / 3 March 1995 107
WHO AKE WE?
The Iowa Medical Group Management Association is a nonprofit organi-
zation whose membership is comprised of individuals engaged in the
administrative aspects of medical group practice. Our membership is
diverse, representing group practices operating under various organiza-
tional and financial structures. Current membership in IMGMA includes
over 500 people representing almost 3,500 physicians.
WHO CAN RELdMCS?
There are four classifications of members: active, affiliate, honorary and
life. Active membership is limited to persons who are serving in an
administrative capacity within a physician group practice, with the
exception of honorary, life and affiliated members. Affiliate members
are individuals who supply products or services to IMGMA members.
WHY JOIN I1WIC3SW1A?
1 IMGMA enhances your professional growth, development and
viability as a medical group manager.
2 IMGMA offers a variety of targeted educational opportunities.
3 IMGMA provides opportunities for members to share and dissemi-
nate information of mutual interest.
4> IMGMA maintains an active liaison with other key public and
private organizations that affect the management, funding and
delivery of quality physician care.
5 IMGMA dues are only $75 per year.
IOWA MEDICAL GROUP MANAGEMENT ASSOCIATION
iOOl Grand Avenue, West Des Moines, SA 50265
Please send me an application for membership!
Name Position
Organization
Address
City/State/Zip
Telephone Number Number of Physicians
Iowa [Medicine
GUEST EDITORIAL
King Will and the Foul
Humours: a fable for reform
Ladies and gentlemen, over the course of
the last two years, we’ve been asked to
believe several fairy tales in the name of
health system reform. So today, I’d ask your
indulgence as I tell one last fairy tale.
I’d like to tell you the story of King Will and
the Foul Humours.
Once upon a time there were a King and
Queen who lived in a big, white castle, sur-
rounded by a big, black fence, that was regu-
larly patrolled by knights wearing dark visors.
Before King Will had become King, he lived
in the forest, where he took from the rich and
gave to the poor. This made him quite popu-
lar— especially with the poor — but he mistook
his popularity for wisdom, and no sooner had
he moved into the white castle than he began
searching throughout the Kingdom
for problems to solve.
He said to the Queen “Queen
(he always addressed her in this
manner) do you perceive any prob-
lems that criest out for solutions?”
She replied: “Are you kidding?
The knighthood could use a little
more diversity. The plague is making
a comeback. And every time you take your exer-
cise, you can’t stay away from the butcher shop.”
Now the king ignored this last comment, but
the problem of the plague seized his mind.
He knew many of his subjects were unable to
see the Wizards — Doctors of Physic who minis-
tered to the ill. And he knew the tithe for having
their humours checked was rising faster than
the Consumer Price Index.
But the King knew the magic of the Wizards
was unsurpassed. Citizens from neighboring
kingdoms would travel many leagues just to see
them. The vast majority of his subjects were
contented with their care and could see a
Wizard almost whenever they wanted to.
The King mulled over his dilemma — he was
famous for mulling and wonking — and finally,
he said to the Queen: “It is up to us to give the
people the health care they deserve.”
Now a strange thing happened. The Queen
might well have turned to the Wizards, who
themselves had been discussing this problem
and recommended remedies for many years.
But instead, she summoned a noted sorcerer
from a far away land, Ira of the Unruly Hair.
And Ira gathered a legion of fellow sorcerers,
and convened them in a secret
Star Chamber, a place so dank and
dark no light could enter or es-
cape.
They labored while the Spring
blossoms scented the trees and the
sun ripened the fruit on those trees.
They labored while the leaves on
those trees began to fall to the
earth. Then one day the Queen sent a crier
throughout the Kingdom to announce that Ira of
the Unruly Hair had indeed produced a mighty
plan and it would be wondrous to behold.
Then they gathered every beast of burden in
the Kingdom, all the oxen and horses and mules,
and they hitched them to the machine on which
they had placed the great plan — for the plan was
not only great in inspiration but great in size —
She
summoned
a noted
sorcerer, Ira
of the
Unruly Hair.
Robert McAfee, MD
AMA president
Dr. McAfee, a surgeon
practicing in Maine, gave
this farewell speech at
the AMA Interim Meeting
in Hawaii.
Iowa Medicine Volume 85/ 3 March 1995 109
Iovval Medicine
But the elephants
said the people
were tithed too
much and the
money was wasted
on things like
midnight falconry.
Guest Editorial
continued
and they hauled it to the big, white castle and
presented it to King Will.
King Will, chewing on the drumstick of a
great wonk, placed his seal upon the plan.
Now on a hill looking down on the white
castle was a Great Hallowed Hall with a round
dome. In that Hall were knights of renown from
every other castle in the Kingdom.
They were divided roughly into
two camps. The shields of one camp
bore the sign of the donkey; the shields
of the other the sign of the elephant.
It was these knights’ job to decide
the laws of the land, but in truth, most
of their days were spent in their favor-
ite sport, jousting. The leader of the
donkeys, Sir George of the Land of Lobster, was
one of the most feared jousters. He said: “Bring
us the plan of King Will, so we can make it the
law of the land.”
And the leader of the elephants, Sir Bobdole
of the Land of Corn, famous for his skill with the
lance, spoke: “This plan has more fat than a
roasted boar,” said Sir Bobdole.
The donkeys and the elephants had oppos-
ing views on the health care of the people. The
donkeys believed the King and the knights
should design the system, and decide what kind
of training should be given to the Wizards and
which Wizards the people could see. The
donkeys believed if the subjects would pay
their tithe to them — they could fix the system.
But the elephants said the people were tithed
too much and the money was wasted on things
like midnight falconry. And they said the King
and the Great Hall should stay out of it. And
they accused the donkeys of being beholden to
a knight of yore, Sir Franklin of the New Deal.
So the knights of the donkeys and the knights
of the elephants devised their own plans: Sir
George of the Land of Lobster, Sir Chafee of
Rhodes, Sir Stark of Fortney, Sir Teddy of
110 Iowa Medicine Volume 85/3 March 1995
Camelot and others. But the champion of one
plan, Sir Rosty of the Windy City, was injured
when he was out delivering a gift to a subject
and fell into a moat.
But these plans, too — five in all — were also
placed on great machines and hauled out to be
viewed by the people. And the knights returned
to their jousting.
And now thick fog hid the sun, and thunder
rent the air, and torrents of rain turned the land
into mud, and the plans of King Will and all the
plans of the Great Hall got bogged down.
All the while the Wizards offered advice and
counsel on the health of the people. And the
people heard them and gave the Wizards their
confidence. But the King and Queen and many
in the Great Hall gave the people only the cold
shoulder and the deaf ear.
Now there arose in the land a new evil that
further threatened the health care of the people.
One day, five great dragons from the King-
dom of Insurers appeared in the sky, and en-
camped in every corner of the Kingdom. And
on their wide wings were markings sinister and
strange. One had what looked like the giant
rock of Gibraltar. Another had what looked like
a great umbrella of crimson. Still a third was
marked with a small cartoon beagle.
People called them the Big Five. They
breathed fire and made a bellowing that was
terrible to hear and were in general unman-
nerly. They began making forays across the
land, swooping down upon unsuspecting sub-
jects, herding them into their own regions.
They swallowed up entire villages. They
plucked up select Wizards, and demanded that
they tend only the citizens they had corralled,
and none other. The citizens raised up a cry
because they could no longer see the Wizards
who had so carefully watched over them.
But as the dragons’s plunder continued, their
appetites grew more ravenous. It was rumored
GUEST EDITORIAL
that some dragons even tried to eat some of the
others. And clouds darkened the sky and a
great indigestion struck the bowels of the people,
and they were sore afraid.
Ladies and gentlemen, most fairy tales end
with everyone living happily ever after. For
that to happen here, you might expect a white
knight to appear and slay the dragons and
knock some sense into the King, the Queen and
the knights of the Hall on the Hill.
But the ending to this story has yet to be
written.
The great plans of the King and Queen and all
the knights of the Ilall got bogged down under
their own weight.
As a result, many knights lost their shields
and left the Great Hall forever — although most
went on to join the Guild of Lobbyists. Some
who remained were hoping to fix the Kingdom’s
health system by mixing up a special magic
potion. Its main ingredient was Eye of Newt.
Most of the knights, however, just went back
to their jousting.
As for King Will and his Queen, the whole
experience was enough to make them wish
they were back in the forest, in their house
surrounded by rushing white water.
The King has taken to traveling to foreign
lands but never misses a chance to remind the
Queen that you just can’t trust a sorcerer.
What remains are the Wizards and the
people — the true heart and soul of any health
care system.
The people will continue to receive the best
care on Earth when they demand nothing less.
We Wizards must never forget that we can
deliver that care only if we’re united in our
vision, our voice and our leadership.
And, I believe we can write a fairy tale ending
if we never forget that the true power of our
magic is not what’s under our hats, but what’s
in our hearts. [HI
Iowa Medicine Volume 85/ 3 March 1995 111
If Your Jeweler
Is Not A Member
Of
You May Want
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of distinguished jewelers in North
America that’s dedicated to consumer
protection. As a member, Josephs has
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Iowa [Medicine
IMS Update
CURRENT ISSUES
AT A GLANCE
IMS leadership has
approved a blueprint for
specialty society repre-
sentation in the IMS
House of Delegates. The
blueprint and amended
bylaws will be submitted
to the IMS House April
29. If adopted, specialty
societies who meet crite-
ria will be eligible to
participate in the 1996
House of Delegates.
•
The IMS Judicial Coun-
cil wants to hear the
views of all IMS mem-
bers regarding the for-
mat of the IMS House of
Delegates meeting. Watch
for a member survey in
the April Iowa Medicine.
•
The American Hospital
Association recently de-
clared a “crisis of confi-
dence” in the Joint
Commission on Accred-
itation of Health Care
Organizations, which
accredits most of the
nation’s hospitals. More
than 10 JCAHO chapters
are considering alterna-
tives; the AHA’s president
said the defection could
lead to JCAHO’s collapse.
Calling all IMS delegates
IMS delegates from across Iowa are
urged to represent their counties at the
1995 IMS House of Delegates and Scientific
Session April 28-30 at the Marriott Hotel,
Des Moines.
The Scientific Session begins with a full
day of programs on Friday, April 28 and
concludes with a panel discussion of
domestic violence on Sunday morning. (A
program with registration information is
enclosed with this Iowa Medicine.)
Election of officers will be held Sunday
morning, April 30. Offices to be filled
include: president-elect, vice president,
trustee, House of Delegates speaker and
vice speaker, two AMA delegates and two
AMA alternate delegates.
IMS delegates should watch their mail
for more information about the meeting,
resolutions submitted, the slate of officer
candidates and delegate handbooks.
Focus on IMS Alliance
Do you know violence when you see it? Or, are you
like many of us who have witnessed so much vio-
lence in our lives we may not even recognize it?
IMS Alliance is asking everyone to “Turn Off the
Violence” on Friday, March 31. We ask that you
turn off violent television programs and violent
music, boycott violent movies, not rent violent
videos and turn off violence in all its ugly forms.
“Turn Off the Violence Day” will be the culmina-
tion of March, Medical Alliance Month. During
March, 1,000 state and county medical alliances
are celebrating by showcasing projects and pro-
grams they have developed to meet the unique
health needs of their communities.
The IMS Alliance has over 1,100 members and is
dedicated to the mission of improving public
health, contributing to the AMA Education and
Research Foundation and advocating sound health
legislation on the state and national levels.
Contributed by Barbara Bell, president, IMSA
Specialty Society Update
The IMGMA will hold a strategic planning session
March 3-4 to examine the future of the group and how
best to meet members’ needs.
Jerry Lewis, MD, legislative chair for the Iowa
Psychiatric Society, also chairs the Mental Health
Advocacy Coalition of all major mental health inter-
ests in Iowa. The Coalition has adopted model legisla-
tion to establish parity for mental health services
under health insurance.
The American College of Cardiology, Iowa Chapter, will
hold a reception March 20 in New Orleans in conjunc-
tion with the ACOC annual meeting.
Roy Overton, II, MD, president of the American
Medical Directors Association, Iowa Chapter, has been
appointed by Governor Branstad as a delegate to the
White House Conference on Aging May 1-5. The AMDA
spring meeting is April 20 at the Crystal Tree Inn, Des
Moines.
New officers of the Iowa Oncology Society are: presi-
dent — George Kovach, MD, Davenport; vice presi-
dent — Roger Gingrich, MD, Iowa City; secretary/trea-
surer — Larry Otteman, MD, Ames. The next board
meeting will be April 26 in Iowa City.
The Iowa Society for Rehabilitation Medicine spring
meeting will be Friday, April 7 at IMS headquarters in
West Des Moines.
The Iowa Association of County Medical Examiners
board of directors will meet February 17 at IMS head-
quarters in West Des Moines to plan for the October
annual meeting.
The Iowa Society of Anesthesiology will hold its annu-
al meeting Saturday, April 1 at the Des Moines
Convention Center.
Doctors' Day is March 30
In 1 99 0, President George Bush signed a
resolution designating March 30 as
National Doctors' Day. The IMS Alliance
salutes the Iowa physicians who serve
our communities every day of the year.
112 Iowa Medicine Volume 85 / 3 March 1995
Iowa [Medicine
CURRENT ISSUES
Futures
Physician-patient relationship at risk
The ideal physician-patient relationship is
being threatened by a number of factors,
including the growth in managed care plans,
according to several articles in a recent issue
of JAMA
The ideal physician-patient relationship is
summarized by the six G’s — choice, compe-
tence, communication, compassion, continu-
ity and (no) conflict of interest.
The authors of the JAMA articles believe
managed care plans have some benefits but
could undermine this relationship. The
authors say these elements are in jeopardy
due to competition among managed care
plans to cut costs and increase productivity.
The AMA’s Council on Ethical and Judicial
Affairs is concerned that financial incentives
offered to physicians by managed care plans
to lower costs could compromise what is best
for patients and constitute a conflict of inter-
est for physicians.
Federal antitrust judgment surprising
A federal jury assessed nearly $50 million
in antitrust damages against the 430-physi-
cian Marshfield Clinic located in central
Wisconsin. Marshfield will appeal the verdict,
a process which could take up to a year.
According to an article in Modern
Healthcare, the verdict “increases the legal
vulnerability of providers trying to gobble up
market share in the name of building region-
al integrated delivery systems.”
The plaintiff in the case is Blue Cross and
Blue Shield of Wisconsin, which charged
Marshfield with eight violations of various
state and federal laws. The court is still con-
sidering the Blues’ other request that
Marshfield be required to sell its HMO and
enough physician practices to end its
“monopoly power”.
In Springfield, Mo., a hospital has agreed to
limit physician practice acquisitions in order
to resolve the state’s antitrust concerns.
AMA calls for Medicare reform
The American Medical Association is calling on
Congress and President Clinton to sit down with
physician leaders and work on the reform of
Medicare, based on six principles that would
increase cost consciousness by patients and more
equitably distribute the burden of financing
between generations.
AMA says the “annual cycle of cuts in benefits
and reimbursement has exacerbated the problem
of Medicare spending growth”. The AMA framework
for Medicare reform was announced by Lonnie
Bristow, MD, the AMA’s president-elect, in a nation-
ally-broadcast address.
“There won’t be any Medicare for the next gener-
ation unless we make serious changes now,” Dr.
Bristow commented.
The AMA’s proposed Medicare treatment plan is
built on the following six principles:
•Medical savings accounts and other instruments
of personal monetary decision-making.
•More equitable financing so hard pressed young
people aren’t saddled with bills for affluent elderly.
•Price competition — relaxing controls.
•Simplification — tearing down the regulatory
maze.
•Physicians join in a campaign to curtail unwant-
ed and inappropriate care, with revision of liability
laws.
•An unrelenting campaign to reduce fraud and
abuse.
Is Congress serious about cuts?
In case you may be wondering whether
members of Congress are serious about cut-
ting the budget and streamlining government,
the Kiplinger Washington Newsletter says
they are. Apparently, members know the vot-
ers expect real cuts, not merely decreases in
the rate of spending as in the past.
However, many experts are predicting cuts
won’t be as deep as promised and that cuts
won’t come easily because virtually every
program has avid supporters. However, noth-
ing is off-limits except Social Security.
AT A GLANCE
Many people in a large
Consumer Reports sur-
vey said they are highly
satisfied with their
physicians but have “a
bone to pick” about
physicians’ communi-
cations skills. Among
the findings reported in
the February issue , 75%
of respondents were
very satisfied with their
doctor; but 50% com-
plained about at least
one aspect of their care,
particularly communi-
cation problems.
•
According to the Wall
Street Journal, HMOs
will continue to show
strong profits. United
Healthcare Corp. is
expected to post a 40%
rise; earnings for
Humana rose 55% dur-
ing the fourth quarter.
continued
Iowa Medicine Volume 85/3 March 1 995
113
Iowa [Medicine
CURRENT I S S U E S
Futures
continued
Business is
booming for
lawyers who
specialize in health
care issues.
Pundits are expecting a big fuss over
Medicare, which will go into the hole in 1996
and be wiped out by 2002 unless something is
done. Though many predict some action this
year or next, it is believed Congress will delay
clashing with senior citizens as long as possi-
ble over proposals such as raising Medicare
premiums for wealthy elderly.
Meanwhile, President Clinton has vowed to
shield Medicare and several other programs
from cuts. These programs amount to rough-
ly half of the federal budget.
Worth repeating
“Reforming health care without talking to
doctors is like reforming courts without talk-
ing to judges. Doctors are willing to share
the sacrifice — so long as we aren’t the sac-
rifice.”
AMA President-elect Lonnie Bristow, MD,
during a National Public Radio broadcast.
AMA policy and Republican contract
The IMS has available an analysis prepared
by the AMA of the Republican Contract with
America and applicable AMA policy. The
analysis has been delivered to Speaker Newt
Gingrich, along with a cover letter arguing for
inclusion of liability reforms and Medical
Savings Accounts in “Contract” legislation.
Congressional Democrats are warning
states that the Contract with America could
cost them hundreds of billions of dollars.
For a copy of the AMA analysis, call Chris
Clark at the IMS, 800/747-3070 or 515/223-1401.
Legal business is booming
According to a recent article in the New
York Times, business is booming for lawyers
who specialize in health care issues. As doc-
tors and other providers scramble to cope
with “the brave new world of joint ventures
and managed care, the new business arrange-
ments and transactions all require lawyers”,
said the Times. EH
Introducing A Bill That
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the dollar.
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to work for you. We’re endorsed for debt collection
services by more than 1,000 business and professional
associations nationwide, including yours.
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IOWA MEDICAL SOCIET
I.C. SYSTEM
114 Iowa Medicine Volume 85/ 3 March 1995
IowalMedicine
Legislative Affairs
Update on legislative issues
Following is an update on selected issues
in the Iowa Legislature of interest to the IMS.
As of press time, the following bills had been
introduced:
Individual health insurance reform
This bill provides protection for individual
health insurance policy holders similar to
those in effect for small group insurance.
Rate restrictions
Restrictions include limiting rate varia-
tions for blocks of business and prohibiting
use of rating characteristics other than age,
geographic area and family composition with-
out approval of the insurance commissioner.
Disclosure
Carriers are also required to make disclo-
sures to prospective customers related to pre-
existing conditions and the extent to which
rates are based on individual rating.
Renewal
Insurers are required to renew policies
unless premiums have not been paid, the cus-
tomer has committed fraud, the individual
becomes eligible for Medicare, the carrier
decides not to do business in Iowa any longer
Contacting Your Legislators
Telephone numbers during the session:
Senators 515/281-3371
Representatives 515/281-3221
Governor 515/281-5211
Write to them at:
STATEHOUSE
Des Moines, Iowa 50319
You may contact your legislators at home
when the Iowa Legislature is not in session. If
you don’t know your legislator’s home address
and phone number, call Lyn Durante of the
IMS staff, 515/223-1401 or 800/747-3070.
or the commissioner finds continuation of
coverage would not be in the best interests of
other policyholders.
Continuation of coverage
Carriers who issue individual health bene-
fit plans must make available a basic or stan-
dard plan to individuals who apply and agree
to meet the provisions of the plan, if the indi-
vidual applies within 30 days of discontinua-
tion of another policy.
Preexisting conditions
The basic or standard benefit plan shall
have no restrictions on preexisting condi-
tions greater than 12 months.
Standards for plans
The commissioner will set standards for
the basic and standard plans.
Statewide trauma plan — SSB 50
This proposal from the Iowa Department
of Public Health is based on recommenda-
tions of the Iowa Trauma System Develop-
ment Project Planning Consortium. Ten
physicians served on the consortium. The
legislation establishes a trauma designation
system for hospitals to help ensure a coordi-
nated system of trauma care. The bill does
not include restrictions on the type of care
that may be provided by any hospital.
Medical savings accounts — IISB 51
This bill allows full deduction of the cost of
health insurance premiums for individuals,
allows a deduction of $1800 for individuals
and $4200 for families for contributions to a
“family health account”. Family health
accounts may be used as a repository for gov-
ernment subsidies for health insurance,
employer contributions for health care, to
receive money from the individual for health
insurance, for purchase of a health benefit
plan, to pay deductibles or copayments, to
pay health care providers and to pay for long-
term care services or insurance.
continued
CURRENT ISSUES
AT A GLANCE
There is still time to reg-
ister for the Iowa
Medical Society’s Medi-
cine Day to be held
Wednesday, March 22.
Iowa physicians and
their spouses will eat
lunch at the IMS, then
travel to the Statehouse
to talk to legislators,
attend committee meet-
ings and hear debate. To
register, call Paul Bish-
op or Lyn Durante at the
IMS, 515/223-1401 or
800/747-3070.
•
The IMS CHMIS Com-
mittee is recommending
adoption by the IMS
House of Delegates of a
“statement of princi-
ples” to guide IMS par-
ticipation in develop-
ment of the CHMIS sys-
tem. See this month’s
Medical Economics Sec-
tion for more details.
Iowa Medicine Volume 85 / 3 March 1995 115
Iowa [Medicine
CURRENT ISSUES
Legislative Affairs
continued
Emergency medical services — SSB 55
The bill consolidates regulation of prehospi-
tal emergency medical services under the
Department of Public Health and would require
all EMS sendees to be licensed by the DPH.
Several liability bills have been intro-
duced, including HF 27, IIF31 and I1SB 17.
These proposals including a $250,000 limit
on noneconomic damages and various limits
on the statute of limitations for minors.
In addition, several key public health bills
have been introduced.
Motorcycle helmet law — SSB 54
Requires motorcycle operators and passen-
gers to wear approved protective headgear
while riding a motorcycle. Operators would be
fined $50, passengers $25 for noncompliance.
Tobacco Free Coalition
The IMS is working with the Tobacco Free
Coalition and the Iowa Department of Public
Health on improving enforcement of the
clean indoor air act and laws related to youth
access to tobacco.
AMA legislative priorities
Medical savings accounts — AMA supports
IRA-tvpe medical expense accounts and
broader, more flexible proposals.
Regulatory' relief/CLIA — AMA is working
with the Clinton Administration and
Republicans in Congress to obtain CLIA
repeal or reform and relief from OSHA blood
borne disease requirements and other bur-
densome regulation.
Professional liability' reform — The AMA
is working with a coalition to ensure that
reforms including a cap on noneconomic
damages are included in the Common Sense
Legal Reform Act of 1995.
Medicare reform — AMA opposes quick fix
reimbursement reductions in favor of reform
which gives the program long-term stability.
(See this month’s Futures section.)
Antitrust relief — Previous proposals died
with health care reform bills. The AMA will
work to provide relief for physicians trying to
compete in the new marketplace. [EH
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Iowa Medicine Volume 85 / 3 March 1995
Iowa |Medieine
CURRENT ISSUES
Medical Economics
IMS policy on CHMIS recommended
The Iowa Medical Society’s CIIMIS com-
mittee is recommending that the House of
Delegates adopt an official statement of IMS
operating principles. These principles will
guide IMS participation in development and
implementation of the Iowa Community
Health Management Information System. The
proposed policy statement will be submitted
for approval to the IMS House of Delegates
next month. The policy statement addresses
key issues of concern to physicians, such as
confidentiality and cost implications.
Iowa’s CHMIS, signed into law by Governor
Branstad last April, 1994, is scheduled to be
implemented in three phases.
Phase 1, electronic claims submission, will
go into effect July 1, 1996. Phase 2 will
involve expansion of data collected from
physicians and will be implemented July 1,
1999. Phase 3 may involve patient-specific
electronic medical records. Phases 2 and 3
cannot be implemented without further
action by the Iowa Legislature.
Iowa physicians are represented on the
CHMIS Governing Board and on the
Governing Board’s five advisory committees.
Physicians on the Governing Board and advi-
sory are also ex-officio members of the Iowa
Medical Society’s CHMIS Committee.
At a meeting January 24, the IMS CHMIS
Committee received an overview of CHMIS
activities from Dr. Dale Andringa, a member
of the CIIMIS Governing Board. The commit-
tee also heard about activities of the five
Governing Board advisory committees.
The IMS committee held a lengthy discus-
sion during which concerns about various
aspects of CIIMIS were expressed by commit-
tee members. It was emphasized that CHMIS
is a concept at this time; final decisions have
yet to be made on many issues of concern to
physicians. Physician input into the CHMIS is
crucial, said Dr. Terrence Briggs, chair of the
IMS CHMIS Committee.
History of CHMIS development
The Iowa Medical Society has been
involved in the CIIMIS process since the sys-
tem was first proposed several years ago. At
that time, CIIMIS was touted as the informa-
tion component of health system reform in
Iowa. The idea of a CHMIS for Iowa gained
solid support very early in the process due to
increased demands from business and con-
sumer groups for health care accountability.
“The Iowa Medical Society asked for a seat
at the table and was able to vastly improve
the legislation which was eventually intro-
duced in the Iowa Legislature,” comments Dr.
Briggs. “The very first proposals involved
simultaneous implementation of electronic
continued
Iowa Medical Society holds CHMIS informational meetings
IMS staff have been presenting a CHMIS overview to many county medical societies across Iowa.
As part of the Society’s continuing effort to educate member physicians about CHMIS, the follow-
ing additional CHMIS informational meetings have been scheduled.
March 7, 5:30 p.m., Outing Club
April 7, 9:00 a.m., Marriott Hotel
April 26, Noon, University of Iowa
Scott County Medical Society
Des Moines (Iowa Psychiatric Soc.)
Iowa Oncology Society
March 8, 7:30 a.m., Genesis East
April 10, 6:00 p.m., Hospital Bd. Room
May 6, 9:00 a.m., University Park
Davenport
Storm Lake
Des Moines (la. Urological Soc.)
March 20, 6:00 p.m., Hospital Bd. Room
April 22, 9:00 a.m., University of Iowa
Mahaska County Medical Society
Iowa Clinical Society of Internal Med.
AT A GLANCE
On April 1, 1995, Med-
icare Part B will change
to a computer process-
ing system called MCS.
This change does not
change Medicare rules
and you can continue to
submit your EMC trans-
missions as usual.
However, there will be a
completely different pro-
vider remittance notice.
Watch your Medicare
Infos for additional de-
tails.
•
The ABI Workers Com-
pensation Seminar will
be March 14, 1995 at the
Hotel Fort Des Moines.
For registration informa-
tion, call Barbara Heck
of the IMS staff, 515/223-
1401 or 800/747-3070.
•
USA Today reports that
there is a trend among
hospitals to lay off RNs
and have less trained
workers do patient care
once reserved for nurses.
Iowa Medicine Volume 85 / 3 March 1995 117
Iowa|Medicine
CURRENT ISSUES
Medical Economics
continued
claims processing, a central data repository
and electronic patient records.”
Due to IMS involvement, Dr. Briggs adds,
the proposal which was finally introduced in
the legislature broke these components into
three phases — with phases 2 and 3 requiring
additional legislative action before implemen-
tation. IMS representatives were able to
include other physician-friendly provisions
into the legislation.
At the January meeting, the IMS Cl IMIS
Committee also reinforced the need for a
timely communications link between IMS
member physicians and the physicians serv-
ing on the CHMIS Governing Board and advi-
sory subcommittees.
Benefits of CHMIS Phase 1
•According to a national study by WEDI,
physicians will save $1.07 per claim through
electronic submission.
•There will be less administrative hassle
since every insurance company will have to
accept one standard claims format.
•There will be a faster turnaround time for
payment of claims.
•Physicians will have access to useful data
on practice patterns.
•The CHMIS will replace the current Health
Data Commission and data collection efforts
will be made easier for physician offices.
Iowa’s Medicaid plan awash in lawsuits
According to a story in the Des Moines
Register, two more health care management
companies are suing the state of Iowa to pre-
vent the Department of Human Services from
awarding a $100 million contract for psychi-
atric care of Iowa’s Medicaid patients.
The companies were unsuccessful bidders
for the contract. They are asking Polk County
District Court to end negotiations between
Iowa DIIS officials and Medco, which was
awarded the contract in December. The com-
panies are also asking that the entire bidding
process be reopened.
As of press time, Medco was scheduled to take
over management of psychiatric services for
Iowa’s 190,000 Medicaid patients March 1. US]
We're At Your Service
For nearly 20 years we've helped Iowa Medical Society members meet the challenges
of our ever-changing healthcare environment.
Quality Products: We stock a full line of private-label ABCO
alternatives as well as brand-name products at competitive prices.
Personalized, Responsive Service: From our toll-free order and
inquiry number to free equipment support, we’re dedicated to
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(319)337-3121 (319) 386-1345 (515)274-4015 (815) 226-5757 (309) 637-6058
118
Iowa Medicine Volume 85 / 3 March 1995
“You Asked for It! We Have It! 99
l
Specialty
Coding
Extravaganza
Date: April 18, 19, 20, 1995
Time: 8:30 a.m. to 4:30 p.m.
Where: Best Western Des Moines International,
1810 Army Post Road, Terrace 4
Nancy Maguire, RN, CPC, GPG-H, CRT, executive director of education
and the dean of AAPG University, will be in Des Moines for a three-day
specialty coding workshop. Ms. Maguire will field questions on all aspects
of GPT, IGD-9-GM, HGPGS coding and also supply helpful tips in internal
office control.
Tuesday, April 18
8:30 a.m. to 12:00 noon — PEDIATRICS
“Get practical advice to avoid reimbursement pitfalls.”
1:00 p.m. to 4:30 p.m — SURGICAL CODING
“Bill the right surgical codes every time and avoid duplication and unbundling edits.”
Wednesday, April 19
8:30 a.m. to 4:30 p.m.— PRIMARY CARE
“Avoid mistakes in E & M codes, modifiers and effective internal office controls.”
Thursday, April 20
8 30 a.m. to 4:30 p.m — ORTHOPEDIC SURGERY, NEUROSURGERY AND ENT
“Get the best of tricky surgical codes and surgery modifiers with discussion on actual operative notes.”
COST:
1 full day: $175 for IMS member or staff, $280 for non-member or staff
1/2 day: $110 for IMS member or staff, $175 for non member or staff
1 1/2 day: $260 for IMS member or staff, $430 non-member or staff
2 full days: $320 for IMS member or staff, $530 for non-member or staff
3 days: Call IMS for details.
Continental breakfast and
lunches served for full days.
Refreshments during breaks.
s
Health
Insurance
Overview
Tues, 4/11
Wed, 4/12
Thurs, 4/13
Tues, 4/25
Wed, 4/26
IMS Headquarters, Taylor Room, West Des Moines
St. Luke’s Regional Medical Center, Room 2, Sioux City
North Iowa Mercy Health Ctr, West Campus, Mason City
Bettendorf Medical Plaza Conference Center, Davenport
Jennie Edmundson Memorial Hospital, Auditorium,
Council Bluffs
This seminar is an overview of the basics of health insurance including insurance principles, contract and
benefit highlights, insurance claim filing systems, tips for trouble-shooting claim payment problems and
post-payment monitoring systems. It includes information on Medicare, Medicaid and private insurance.
Seminar time is 9:00 a.m. to 4:00 p.m. The cost, which includes lunch, is $150.00 for an IMS member or
staff and $240.00 for non-member or staff.
★ This program is part of the IMS Medical Business Specialist (MBS) Certificate Program.
Registration on reverse side
Please copy this form and complete a separate
registration form and separate payment for each program
Registration Form
Specialty Coding Seminar
Name(s):
Clinic/Practice Name:
Address:
Phone: Fax:
Amount Enclosed: Date:
Please make checks payable to IMS Services. Mail check and registration form to:
IMS Services
ATTN: Sherry Johnson
1001 Grand Avenue
West Des Moines, IA 50265-3599
Registration Form
Health Insurance Overview
Name(s):
Clinic/Practice Name:
Address:
Phone: Fax:
Amount Enclosed: Date:
Please make checks payable to IMS Services. Mail check and registration form to:
IMS Services
ATTN: Sherry Johnson
1001 Grand Avenue
West Des Moines, IA 50265-3599
CURRENT ISSUES
owa | Medicine
Practice Management
Ifou asked for it, we have it!
Do you want answers to tough questions on
all aspects of CPT, ICD-9 and HCPCS coding?
The Iowa Medical Society and IMS Services
will sponsor a coding extravaganza Tuesday,
Wednesday and Thursday, April 18, 19 and
20 at the Best Western Des Moines
International.
Nationally known coding expert Nancy
Maguire will teach the seminars. Maguire is
executive director of education and the dean
of the American Academy of Procedural
Coders.
The first session on Tuesday, April 18 will
cover Pediatric Coding from 8:30 a.m. until
noon. The afternoon session from 1:00 p.m.
to 4:30 p.m. will cover Surgical Coding.
On Wednesday, April 19, the session will
be devoted to Primary Care Coding and
i avoiding mistakes in E & M Codes and modi-
fiers.
Orthopedic Surgery, Neurosurgery and
ENT Coding will be in the spotlight on
Thursday, April 20. This seminar will cover
how to get the best of tricky surgical codes.
All sessions will be held at the Best
Western Des Moines International from 8:30
a.m. until 4:30 p.m.
The cost for a full-day seminar (IMS mem-
ber or staff) is $175; $280 for a nonmember.
This includes lunch. The cost for a half-day
seminar is $110 for an IMS member; $175 for
a nonmember.
The cost of attending two full days is $320
for an IMS member or staff; $530 for a non-
member. The cost for attending one and a
half days is $260 for an IMS member or staff;
$430 for nonmembers.
For more information on these specialty
coding seminars, call Mary Reinsmoen at IMS
Services, 515/223-2816.
Documentation review service
In late summer or early fall of this year, the
Health Care Financing Administration plans
to start auditing physician offices for medical
record documentation that correctly sup-
ports charge and diagnosis codes.
If you feel you need assistance with the
new documentation guidelines, staff at IMS
Services may be able to help.
If you would like an on-site review of your
E & M Coding documentation — including a
review of your charts — IMS staff is available
to assist you.
For further information on arranging an
on-site visit and on fees, call Mary Reinsmoen
at the IMS, 515/223-2816 or 800/728-5398.
Are you communicating effectively?
In a recent survey done by Consumer
Reports, 75% of respondents said they are sat-
isfied or very satisfied with their physician.
Overall, 50% of respondents complained
about one aspect of their care — physician
communication skills. E3
1
Practice Management Workshops for You
Health Insurance Overview
Tues., April 11
Wed., April 12
Thurs., April 13
Tues, April 25
Wed., April 26
IMS headquarters
Sioux City
Mason City
Davenport
Council Bluffs
For more information or to register for any IMS prac-
tice management workshop, call Mary Reinsmoen or
Sherry Johnson at IMS Services, 515/223-2816 or
800/728-5398.
Coding Seminars April 18, 19, 20
(All sessions at Best Western, Des Moines International)
Pediatric, Surgical Coding April 18
Primary Care Coding April 19
Orthopedic Surgery/Neurosurgery April 20
and ENT Coding
Taught by Nancy Maguire, director of education
and dean of the American Academy of Procedural
Coders. (See story above for additional details.)
AT A GLANCE
Usage reports indicate
IMS member physicians
who are using the
Airborne Express pro-
gram have experienced
an overall savings of
43.7%. For more infor-
mation, call Sandy
Nelson at IMS Services,
515/223-2816 or 800/
728-5398.
•
Watch your mail for
information on a new
individual travel club
program which will be
available soon through
IMS Services.
•
Reminder: bloodborne
pathogens training is
required annually for
all employees (and ini-
tially for new employ-
ees).
Iowa Medicine Volume 85 / 3 March 1995 119
Iowa [Medicine
CURRENT ISSUES
Practice Management
continued
Midwest Medical Insurance Company Focus on Risk Management
Failure to diagnose colon cancer
Failure to diagnose colon cancer is one
of the most frequent and costly malprac-
tice claims made against physicians.
Colorectal cancer is the second leading
cause of cancer deaths in the U.S. Nearly
50% of patients with colon cancer die from
the disease.
A study by the Physician Insurers
Association of America of 151 closed mal-
practice claims involving delay in diagnosis
of colon cancer showed several factors
contribute to the delay or missed diagno-
sis:
•Failure to perform an endoscopic
exam. In 73% of cases, the cancer could
have been diagnosed by sigmoidoscopy.
•Failure to perform a barium enema.
•Failure to adequately respond to symp-
toms of rectal bleeding, abdominal pain
and cramping, changes in bowel habits,
anemia and weight loss.
•Failure to elicit a patient and family
history.
•Failure to check for occult blood.
•Failure to further investigate guaiac pos-
itive stools when hemorrhoids are present.
•Lack of follow-up care with no system
to find out whether patients returned as
advised.
•Lack of communication between
treating physicians regarding who is
responsible for follow-up.
For further information, contact Lori
Atkinson, MMIC risk management coordina-
tor, MMIC West Des Moines office, PO Box
65790, West Des Moines, 50265, 800/798-
9870 or 515/223-1482.
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120 Imna MpAirinp Volume 55 / .3 March 7995
FACTS ABOUT
CANCER
IN IOWA
Prostate cancer will comprise 30
percent of all new cancers in males
Rates of new cancers have increased
41% among males and 23% among
females when comparing 1973 to
1992
Every year five out of six cancers
occur in Iowans 55 years of age and
older
Visit your physician regularly
Early detection is important
Newly diagnosed breast cancer will
comprise 30 percent of all new
cancers in females
Teach the practice of
self-examination
In 1995, an estimated 6,545 Iowans will
die from cancer, 14 times the number
caused by auto fatalities. Cancer is second
only to heart disease as a cause of death.
These projections are based upon data from
the State Health Registry of Iowa. The
registry has been recording the occurrence
of cancer in Iowa since 1973.
As one of ten registries in the country
funded by the National Cancer Institute
(NCI), Iowa represents the rural and
Midwestern populations and provides data
found in many NCI publications.
Produced by
STATE HEALTH REGISTRY OF IOWA
The University of Iowa, 100 Westlawn S.
Iowa City, IA 52242-1100 (319) 335-8609
The State Health Registry of Iowa is located at The University of Iowa
in the College of Medicine's Department of Preventive Medicine and
Environmental Health. The staff includes more than 50 people. Half of
them, situated throughout the state, regularly visit hospitals, clinics, and
medical laboratories in Iowa and neighboring states. In 1995, data will be
collected on 15,400 new cancers among Iowa residents. A follow-up program
tracks more than 97 percent of the 270,000 Iowans diagnosed with cancer
since 1973. This program provides regular updates to keep the data current
and useful.
This excerpt provides information from the State Health Registry's
annual publication 1995 Cancer in Iowa.
ESTIMATED NUMBER OF NEW CANCERS IN IOWA FOR 1995
CANCER PROJECTIONS
FOR 1995
Cancer affects Iowans of all ages and
in every county. In 1995, cancer will
strike five out of every 1,000 and bring
death to two of them.
ESTIMATED NUMBER OF CANCER DEATHS IN IOWA FOR 1995
Breast cancer is the most common
female cancer and, along with colon,
rectum, and lung cancers, will account
for more than half of all new cancers.
Lung cancer is the most common cause
of cancer death in females followed
closely by breast cancer.
Prostate, lung, colon, and rectal
cancers account for over 60 percent of
all new cancers in males. Lung cancer
causes almost one-third of all male
cancer deaths.
TOP 10 TYPES OF CANCER IN IOWA ESTIMATED FOR 1995
New Cancers in Females
TYPE # OF CASES % OF TOTAL
BREAST
2225
30.5
COLON & RECTUM
1125
15.4
LUNG
790
10.8
UTERUS
440
6.0
NON-HODGKIN'S LYMPH.
315
4.3
OVARY
290
4.0
LEUKEMIA
210
2.9
SKIN MELANOMA
190
2.6
PANCREAS
185
2.5
KIDNEYS RENAL PELVIS
160
2.2
ALL OTHERS
1370
18.8
TOTAL
7300
TYPE # OF CASES % OF TOTAL
LUNG
600
19.4
BREAST
565
18.3
COLON & RECTUM
425
13.7
OVARY
175
5.7
PANCREAS
160
5.2
NON-HODGKIN'S LYMPH.
150
4.8
LEUKEMIA
120
3.9
UTERUS
95
3.0
BRAIN
75
2.5
MULTIPLE MYELOMA
75
2.4
ALL OTHERS
650
21.1
TOTAL
3090
New Cancers in Males
TYPE # OF CASES % OF TOTAL
PROSTATE
2500
30.9
LUNG
1410
17.4
COLON & RECTUM
1040
12.8
NON-HODGKIN'S LYMPH.
310
3.8
LEUKEMIA
250
3.1
BLADDER
250
3.1
SKIN MELANOMA
210
2.6
KIDNEY & RENAL PELVIS
205
2.5
ORAL CAVITY
185
2.3
PANCREAS
170
2.1
ALL OTHERS
1570
19.4
TOTAL
8100
TYPE # OF CASES % OF TOTAL
LUNG
1120
32.4
PROSTATE
455
13.2
COLON & RECTUM
395
11.4
PANCREAS
165
4.8
LEUKEMIA
150
4.4
NON-HODGKIN'S LYMPH.
150
4.3
BLADDER
100
2.9
ESOPHAGUS
95
2.8
BRAIN
95
2.7
STOMACH
80
2.3
ALL OTHERS
650
18.8
TOTAL
3455
ancer remains the second most
ommon cause of death behind heart
isease. The percentage difference
etween heart disease and cancer is
arrowing.
ancer occurs in people of all ages,
Ithough more than 80 percent of all
ew cancers occur in those 55 years
f age and older.
TOP 10 CAUSES OF DEATH IN IOWA ESTIMATED FOR 1995
CAUSE
HEART DISEASE
CANCER
CEREBROVASCULAR DISEASE
NO.
8990
6545
1960
PERCENT
33.0
24.0
7.2
CHRONIC OBSTRUCTIVE & PULMONARY
—
1200
4.4
PNEUMONIA
■
1170
4.3
ACCIDENTS
m
1065
3.9
DIABETES
■
545
2.0
ARTERIOSCLEROSIS
i
380
1.4
OTHER ARTERIAL DISEASES
i
355
1.3
INFECTIONS
i
325
1.2
ALL OTHER CAUSES
4715
17.3
TOP 3 TYPES OF NEW CANCERS IN IOWA ESTIMATED FOR 1995:
Females & Males by Age Group
TYPE # OF CASES
Ages
BREAST
COLON & RECTUM
LUNG
690
595
240
75+
PROSTATE
1100
LUNG
460
COLON & RECTUM
430
Ages
BREAST 965
LUNG 470
COLON & RECTUM 460
55-74
PROSTATE 1400
LUNG 840
COLON & RECTUM 530
Ages
BREAST 570
UTERUS 100
CERVIX 85
15-54
LUNG 110
SKIN MELANOMA 85
COLON & RECTUM SU__
LEUKEMIA 10
Ages
BRAIN 5
Under
BONES & JOINTS 5
LEUKEMIA 15
15
BRAIN 10
NQN-HQPGKIN'S LYMPH. 5
Fortunately for Iowans, the chances of being diagnosed with many
types of cancer can be reduced through positive health practices such as
smoking cessation and healthful dietary habits. Early detection through
self-examination and regular health checkups can dramatically improve
cancer treatment and survival. The 1990s have shown increasing numbers of
non-invasive breast cancers, largely the result of early detection due to
mammography screening. Preventive measures and early detection should
continue to show positive changes in the cancer statistics reported by the
registry.
Iowa [Medicine
CURRENT ISSUES
Newsmakers
Domestic violence response
Dear Editor:
I want to thank you for all you did to make
the January issue of the journal so informative.
Your insight into the issue of domestic violence
was obvious and the articles were effectively
presented for this group of health care profes-
sionals. I’ve received great feedback. — Kay
Maher-Sharp , Family
Violence Center, Des
Moines.
Achievements
Dr. Richard Williams,
professor and head of
the Department of
Urology, UI College of Medicine, has been ap-
pointed to occupy the first Rubin H. Flocks
Chair in Urology. The following physicians have
been elected officers of the Polk County Medi-
cal Society: Dr. Steven Phillips, president-
elect; Dr. Michael Witte, secretary-treasurer;
Dr. Steven Cahalan, councilor and Dr. Lynn
Struck, trustee. Dr. Scott Thiel, family practi-
tioner at McFarland Clinic in Boone, won hon-
orable mention at an Ames art show for his
pastel print entitled “Uncle Clarence and Aunt
dates.” Dr. Tolbert Fellows, UI professor of
physiology, is president-elect of the Associa-
tion of Neuroscience Departments and Pro-
grams. The organization works to advance edu-
cation and research training in neuroscience.
The 1995 medical staff officers of the Mercy
Medical Center in Cedar Rapids are Dr. Fred
Pilcher, orthopaedic surgeon with Iowa Medi-
cal Clinic, president; Dr. Darrell Dennis,
pulmonologist with Internists, P.C., vice presi-
dent and Dr. Alan Robb, family practitioner,
secretary-treasurer. Dr. Mark Thompson, UI
fellow associate in pediatrics, received the
Kinney Award for Young Pediatric Researchers
for his presentation at the Midwest Society for
Pediatrics Research annual meeting. Dr. Rich-
ard Tyler, UI professor of otolaryngology, re-
Letter
to the
Editor
ceived a Special Recognition Award from the
American Tinnitus Association for his commit-
ment to tinnitus research and education. Dr.
Otmar Albrand has relocated from Ogden to
Dubuque where he will be practicing
neurosurgery at Grandview Medical Center.
New members
Iowa City
Douglas Boatman, MD, diagnostic radiology
William Daniel. Jr., MD, diagnostic radiology
Alan Fedge, MD. diagnostic radiology
Ingrid Goldenstein, MD, pediatrics
Robert Hertig, Jr., MD, resident
Wayne Janda, MD. orthopedics
Denise Kolbert, MD, resident
Paul Skopec, MD, diagnostic radiology
Timothy Skopec, MD, diagnostic radiology
John Stamler, MD, ophthalmology
James Wiese, MD, diagnostic radiology
Kalona
Nancy Nelson, MD, family practice
Keokuk
Robert Lorey, DO, obstetrics/gynecology
Mason City
Jonathan McLaughlin, MD, general surgery
Kevin Rier, MD, urology
Marshalltown
Michael Sickels, MD, internal medicine
Mediapolis
Russell Lyons, DO, internal medicine, family
practice
Nevada
Perry Rathe, MD, family practice
Deceased member
Gary Castle, DO, 58, Coon Rapids, died
December 25 Hu]
AT A GLANCE
The Allied Health Com-
mittee of the Iowa Board
of Medical Examiners re-
cently approved three
Lake City Family physi-
cians for the Iowa Volun-
teer Physician Program:
Dr. Dale Christensen. Dr.
Robert Ferguson and Dr.
Ashton McCrary. Dr. Rob-
ert Mc-Cool, Clarion, has
also been approved for
the program.
•
Details on the 1995 IMS
House of Delegates and
Scientific Session can be
found in the program in
the center of this issue of
Iowa Medicine.
Iowa Medicine Volume 85/ 3 March 1995 121
Iowa | Medicine
FEATURE ARTICLE
Robert Krypel, JD
Mr. Krypel is a partner in
the Chicago office of
Healthcare Management
Consultants, LP. He is a
frequent contributor to
Modern Healthcare,
Medical Economics and
other publications.
Pitfalls o f
integration
A decision to integrate should be made only after a thorough
analysis of what the physician has to gain and the potential
risks. The author analyzes several of the models for
physician/hospital integration found in today’s marketplace.
concern about giving up control of the
Though it is clear that physicians should
be alert to the potential pitfalls associated
with various health care integration models,
this does not mean physicians should shy
away from employing these new strategies to
cope with today’s shifting environment.
It does mean all factors must be weighed
against the potential benefits of increased
managed care contracts, reductions in
practice overhead and better management.
This is a major business decision for
physicians which must be made carefully.
Changing strategy for hospitals
The evolution towards vertical integration
of the health care delivery system has
resulted in development of a new strategy by
hospitals and hospital systems — namely,
purchase of predominantly primary care
practices and employment of physicians as
part of a single delivery system.
The primary result is that more
private practice physicians
become employees of hospitals or
hospital systems. Many physicians
are reluctant to sell their practices
and become employees (or inde-
pendent contractors) of the
hospital system for several reasons:
practice; concern about the hospital’s ability
to effectively manage the office; fear of
termination if the hospital finds a physician
who will work for less money; a change in
attitude required to become an employee;
lack of incentive to make the business grow;
concern over being insured by the hospital’s
choice of malpractice carrier; reduced
options if the hospital makes the wrong
decision in terms of overall management or
managed care contracting.
Thus, alternative structures have evolved
which deliver physicians collectively into the
managed care marketplace.
Models for integration
One option is an Independent Practice
Association or a Physician Organization
established to allow unrelated practices to
organize into a single unit in order
to obtain managed care contracts.
These models do not include
patient care except as it relates to
incentive compensation paid to
the IPA/PO for efficient utilization
of inpatient care below a
predetermined target. The IPA/PO
is owned by physicians and
The IPA/PO model
is not the most
efficient to
accommodate
managed care
patients.
122 Iowa Medicine Volume 85/3 March 1 995
FEATURE ARTICLE
association with a hospital occurs only if a
patient is admitted or needs outpatient services.
This model is not the most efficient to
accommodate managed care patients
because there is no uniform effort by the
IPA/PO members to reduce costs. Clinical
results may be uniform, but costs associated
with the delivery of care can vary widely.
The results of this disparity and the need
for capital have led to development of the
Physician Hospital Organization (PHO). It
operates similarly to the IPA/PO except that
a hospital or health system is one corporate
member and the physicians (either as an
IPA/PO or as individuals) constitute another
member. This model allows physicians to
reduce the capital risk associated with
developing an IPA because the hospital
shares start-up costs.
However, the PIIO is also not in a position
to control costs. Unless the PHO is taking full
risk contracts (rare in today’s market), it is
assuming risk on only the professional
component of the contract. Physicians are
unable to share in profits generated by the
hospital as the result of efficient care
provided by physicians. Although a bonus
may be paid to the PHO based on controlling
lengths of stay below a predetermined
amount, this would be available to the
physicians without a hospital partner.
Abdicating responsibility
Finally, experience suggests that if
physicians organize through a PIIO, they
eventually abdicate their responsibility in the
contracting process to the hospital. The
result is an increased risk by physicians
regarding effective control of patients. This
increases the ability of the hospital to take
control by redirecting patients to physicians
employed by the hospital rather than
members of the PHO.
Another model is the solo or small medical
group merger into larger primary care
practices, multi-specialty or single-specialty
group practices. A large medical group can
reduce costs and make the group more
attractive to managed care organizations.
Apprehension about consensus building
However, there are significant obstacles.
One is reluctance by physicians to
underwrite the startup costs such as legal,
accounting and consulting fees. There is also
apprehension regarding creating a structure
that requires consensus building among
disparate members. These obstacles and the
common requirement of physicians to
execute a non-compete covenant often doom
a possible merger.
Finally, even successful mergers cannot
guarantee higher net incomes to members.
A recently developed model is the fully
integrated delivery system, which employs
primary care physicians. However, there are
financial and legal risks.
Even successful
mergers cannot
guarantee higher
net incomes
to the members.
Iowa Medicine Volume 85 / 3 March 1995 123
Iowa [Medicine
FEATURE ft R T I C L E
continued
The Office of
Inspector General
has suggested that
payment for good
will is inappropriate
and subject to
review.
The legal risks include potential violations
of Medicare fraud and abuse statutes,
inurement issues, employment contract
issues and corporate practice of medicine
laws in various states. Although many
physicians have sold their practices to
hospitals in the past, there is a frequent and
mistaken belief that fraud and abuse laws
apply only to the purchaser. In fact, they
apply to both seller and buyer and sanctions
can be civil or criminal.
Payment for good will
Potential legal risks relate primarily to the
purchase price allocated for good will. The
Office of Inspector General has suggested
that payment for good will is inappropriate
and therefore subject to review. An
alternative approach is to pay compensation
to an employed physician which is greater
than the market value of the practice.
Inurement relates to the inability of a tax-
exempt organization such as a hospital to
transfer tax-exempt status to others for
private benefit. To prevent the institution
from jeopardizing its tax-exempt status, the
purchase price must reflect fair market value.
State statutes prohibiting corporate
practice of medicine and enforcement of
those provisions may be lax. Therefore, it is
important for the physician to obtain counsel
to prevent practicing medicine through an
unlicensed business organization.
Restrictive covenants
The contract which outlines the terms of a
physician’s employment subsequent to the
sale of a practice undoubtedly include a
124 Iowa Medicine Volume 85 / 3 March 1995
restrictive covenant limiting the ability of the
physician to practice within a defined
geographical area for a specific period of time
subsequent to termination of the contract by
either party. The physician may be
prevented from hiring any employees of the
employer hospital for a period of one to two
years after termination. Although such
restrictions are necessary for the purchaser,
they must be reviewed by the physician in
order to determine under what circum-
stances the physician may want to terminate
employment by the hospital.
Conditions under which the physician or
the hospital may wish to terminate the
relationship include:
• Cause — reasonably acceptable to both
parties.
• Cost — the hospital can hire competent,
skilled physicians for less money.
• Market shifts — the hospital loses a
managed care contract serviced in part by
the physician.
• Personalities — the hospital or the
physician find they cannot work with the other.
If the physician’s employment is
terminated for any of these reasons, he or
she would be forced to start a new practice
under significantly limited conditions.
Evaluate your options thoroughly
The most important thing to remember is
never make a major business decision
without appropriate analysis of all your
options. Today’s rapidly changing envir-
onment demands nothing less than a
thorough evaluation of the possible benefits
versus the potential pitfalls. DU
Can You Quantify That?
Yes We Can.
At Dale Clark Prosthetics, our
philosophy is simple: provide each
patient with the best possible
prosthetic and orthotic care for the
best possible outcome.
One way that we consistently
provide the most comfortable and
functional prostheses is by using
the CAD/CAM (computer aided
design and manufacturing) system.
With CAD/CAM our
professional staff can
more precisely design
and fabricate a custom
socket, as well as store
complete, accurate patient data.
This provides DCP with the ability
to make quantifiable comparisons
of the changes in a patient's
condition over a period of time.
We are the first facility in Iowa
to offer this state-of-the-art
system. And, as part of our family-
centered care, CAD/CAM benefits
the patient without adding cost to
the prosthesis.
To set up a custom
in-service program,
please call our Waterloo
office at (3 19) 234-4010.
Dale Clark
PROSTHETICS ,INC.
Offices located in Waterloo, Mason City, Coralville, Dubuque, Cedar Rapids, and Des Moines.
STATEWIDE
PHYSICIANS
HEALTH
Over 10,000 individuals are protected by the Iowa
Medical Society-sponsored STATEWIDE PHYSICIANS
HEALTH INSURANCE PROGRAM. It’s stable cover-
age with competitive rates.
If you’re not one of the SPHIP insureds, you may want
to explore the program’s many coverage options —
both medical and dental. We’ll be glad to supply
information specific to you and your practice.
Endorsed and overseen by the IMS for its members,
their families and employees, the SPHIP has been
underwritten by Blue Cross Blue Shield of Iowa
since the program began 40 years ago. Today’s
program incorporates various deductibles and cover-
age formats.
Please call Ruth Clare, Terri DeGroot or Mary Sievers
for information about the program.
BERNIE LBWE & A55BEIATE5. INE.
Insurance Administrators to Professional Associations &
Universities and Colleges
515-222-BB11 1-BBB-942-471B FAX 515-22E-B915
E7D0 Westown Parkway. Suite 41D
West Bes Moines. Iowa 5DB66-1411
iowal Medicine
SCIENCE AND EDUCATION
The Journal
of the Iowa Medical Society
Antibiotic resistance: an emergency we can’t ignore
I # Stephen Rindernecht, DO
In the near future, effects of antimicrobial
resistance will be felt by physicians and
patients alike. Drugs once used to treat infec-
tions are often becoming less effective as bac-
teria adapt to their changing environment. As
a result, physicians are sometimes forced to
prescribe stronger, more expensive and more
toxic antibiotics.
This trend is contributing significantly to
the cost of health care in terms of prolonged
hospitalization, more expensive medications
and increased morbidity and mortality in
patients infected by multiple drug resistant
bacteria. This article discusses organisms
which are major factors in this problem and
reviews steps health care providers can take
to slow this evolutionary process.
The leading causes of otitis and sinusitis,
Streptococcus pneumoniae, Haemophilus
influenzae (nontypeable) and Moraxella
catarrhalis are prime examples of the trend
toward antibiotic resistance. As recently as
1971, all three of these organisms were uni-
versally susceptible to ampicillin. At present,
75-100% of middle ear isolettes of M.
catarrhalis and 20-35% of nontypeable H.
influenzae are resistent to penicillin by pro-
duction of a beta-lactamase.’ Although H.
influenzae Type B has rapidly developed pro-
duction of a beta-lactamase, the current vac-
cine has significantly limited its morbidity
and mortality.
S. pneumoniae is a leading cause of otitis
and a prominent cause of invasive diseases
such as pneumonia, sepsis and meningitis. Its
resistance to penicillin through alterations of
its penicillin-binding proteins on the cell sur-
face has become a worldwide concern. This
alteration in penicillin-binding proteins also
contributes to its evolving resistance to other
antibiotics, including the broad spectrum
cephalosporins. S. pneumoniae resistance
can be intermediate (MIC 0. 1-1.0 mcg/ml) or
high (MIC greater than 2 mcg/ml). In the
U.S., about 7% of invasive isolettes show
some degree of resistance. The rates among
nasopharyngeal isolettes from Tennessee and
Kentucky tended to be much higher, 29% and
33% respectively.2
In the past, poor compliance with medica-
tion was the leading cause of medication fail-
ure when treating tuberculosis. Now, this
problem is compounded by isolettes resistent
to both isoniazid and rifampin: 3.5% nation-
wide and 14% in New York City. These two
drugs have formed the backbone of all tuber-
culosis treatment regimens and there are few
alternative antibiotics.
Staphylococcus aureus which, prior to
1941, was universally suspectable to penicillin,
is a leading cause of nosocomial infections.
Now, nearly all S. aureus are resistent to peni-
cillin and many hospital isolettes are suscepti-
ble only to vancomycin or related gly copeptide.
Neisseria gonorrhoeae, enterococci and
several gram negative enterics are other sig-
nificant pathogens developing a high level of
antibiotic resistance.
Many different mechanisms are involved
in development of antimicrobial resistance.
These mechanisms are the never-ending
adaptations to the selective pressure from
antibiotics. Unless a concerted effort is made
by all health care providers, increases in
morbidity, mortality and health care expendi-
tures will continue. Physicians have an obliga-
tion to limit the emergence of resistance.
There are several effective measures that must
be taken.
No antibiotics should be prescribed for the
treatment of a viral illness (ie, common cold,
influenza). Unfortunately, most diagnoses of
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for March
1995.
Stephen
Rindernecht, DO
Dr. Rinderknecht is a
pediatrician with Iowa
Physicians Clinic in West
Des Moines.
Iowa Medicine Volume 85 / 3 March 1995 127
Iowa I Medicine
SCIENCE AND EDUCATION
Antibiotic resistance: an emergency we can’t ignore
continued
upper respiratory tract infection result in a
prescription for amoxicillin. Resist the temp-
tation to prescribe an antibiotic for these con-
ditions and take time to educate the patient
and discuss symptomatic care and relief.
Antibiotic prophylaxis should be reserved
for specific clinical situations. Prophylaxis for
surgical wounds should be limited to infec-
tion-prone body sites or in patients at high
risk for infection (ie, abnormal heart valve).
The antibiotic should be timed so the blood
level peaks at the time of the procedure and
limited to short duration. Several specific
medical conditions which warrant antibiotic
prophylaxis include:
1. Abnormal urinary tract anatomy or
function predisposing to urinary tract
infection.
2. Recurrent acute otitis media.
3. Past history of rheumatic fever.
4. Close contact with specific pathogens
including:
• Haemophilus Influenza Type B
• Neisseria meningitidis
• Tuberculosis
• Pertussis
5. High risk procedures (ie, dental) in
patients at risk for subacute bacterial
endocarditis.
6. Dirty bite wounds, human and cat bites.
7. Immune suppressed (ie, chemotherapy,
asplenic).
8. Neonatal ophthalmia.
There are many ways the narrowest spec-
trum of antibiotic can be best utilized. Peni-
cillin remains effective for treatment of Group
A beta-hemolytic strep, and should be consid-
ered the treatment of choice.45 Although
many of the new oral cephalosporins are
effective in eradicating the organism from the
posterior pharynx, they lack any clinical
advantage. The expense and unneeded broad
spectrum of activity should limit their use in
treating this common infection.
When minimal inhibitory concentrations
(MIGs) are available on an isolette, they should
be used to select the narrowest spectrum
antibiotic. These same principles apply to IV
administered antibiotics in the hospital. Hospi-
tal epidemiologists have closely followed trends
in nosocomial infections involving antibiotic
resistant bacteria. This evolving problem in the
hospital setting has led to the development of
antibiotic restriction policies by many hospital
infection control committees.
Amoxicillin remains the drug of choice for
initial empiric treatment of otitis media. The
new broad spectrum antibiotics have demon-
strated no therapeutic advantage. Treatment
for beta-lactamase producing organisms or
resistant S. pneumoniae should be consid-
ered only when amoxicillin has failed.
If antibiotics are to remain viable treatment
choices in the future, more prudent use will be
required. The effects of antibiotic use goes
beyond the individual to the entire community.
References
1. Lieberman, JM: Bacterial resistance in the ’90s.
Contemp Pediatr 1994;11:72-99.
2. Friedland, IR and McCracken, GH: Management of
infections caused by antibiotic-resistant Streptococcus
pneumoniae. N Engl J Med 1994;331:377-81.
3. Sepkowitz, KA, et al. Trends in the susceptibility of
tuberculosis in New York City. Clini Infect Dis 1994;18:755.
4. Markowitz, M: Treatment of Streptococcal pharyn-
gitis: reports of penicillin’s demise are premature. J Pedi-
atr 1993;123:679-85.
5. Shulman, ST, et al: Streptococcal pharyngitis: the
case for penicillin therapy. Pediatr Infect Dis J 1994;13:
1-7. [ED
128 Iowa Medicine Volume 85 / 3 March 1995
Iowa [Medicine
THE EDITOR COMMENTS
What a difference
a generation makes
It may seem that consideration of managed
care and the treatment of infections have
no relationship. They do; for both under-
score the tremendous changes during the past
decades. The physicians in practice today face
entirely different situations than those of my
generation.
In the late 1940s and early 1950s, antimicro-
bials first became our closest ally in fighting
infections. From the introduction in 1935 of
the red sulfonamide — prontosil — to the exotic
antibiotics of today, innumberable lives have
been saved. The triumphs of the use of prontosil
in the treatment of puerperal sepsis ranks with
the advances in antisepsis promulgated by
Lister.
Though Fleming is credited with the discov-
ery of penicillin in 1929, it was not
until 1940 that Chain, Flory and
associates were able to produce
significant quantities of penicillin
for clinical use. By 1949 the supply
of the “wonder drug” was unlim-
ited. Subsequently, penicillins and
cephalosporins became a large fam-
ily sharing features of chemistry,
mechanism of action, pharmacologic and chemi-
cal effects as well as immunologic charac-
teristics. In turn we witnessed the introduction
of various sulfonamide derivatives, tetracy-
clines, chloramphenicol, aminoglycosides,
polymyxin and on and on.
Penicillin came into general use during my
senior year of medical school ( 1948), and it has
been wonderful to see introduction of the other
infection-fighting agents.
As indicated in Rinderknecht’s article on
page 127 and editorialized in the September
1994 issue of South Dakota Journal of Medi-
cine the major problem in the use of
antimicrobial agents is the ever increasing inci-
dence of resistance by many prevailing
organisms. Our most valuable tools are becom-
ing a source of increasing problems. A recent
article in JAMA (January 18, 1995) indicates
that office-based physicians are prescribing
more expensive broad-spectrum antibiotics.
Some help comes with new vaccines, (e.g.
hemophilus) but still there are many infections
that are difficult to combat.
What of the business of medical practice?
The way our offices operate also has undergone
striking change. From the simple
methods used by the receptionist/
bookkeeper five decades ago we
now have complex office manage-
ment challenges as well as the skills
to deal with them. Third parties
have intruded into the doctor-pa-
tient direct relationship. In order
to compete, the ubiquitous com-
puter has become as important as the stetho-
scope.
The physicians of today face hurdles and
they too will conquer them. Accept new meth-
ods of practice — business as well as
clinical — and our profession shall remain an
honorable one. But, use the methods judi-
ciously. m
To compete,
the ubiquitous
computer has
become as
important as
the stethoscope.
t
Marion Alberts, MD
Iowa Medicine Volume 85/ 3 March 1995 129
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
IowalMedicine
THE ART OF MEDICINE
Inflict kindness
For several fall semesters I’ve had the pleas-
ant responsibility to meet weekly with a
small group of freshman and another group
of sophomore medical students. I gain the
strong impression from these contacts that, in
general, what they seek for their medical ca-
reers and their lives is “to take care of sick
people,” not “to be a health care provider who
sells health care products to health care con-
sumers.” Cynics contend those statements are
equivalent. I strongly disagree.
Cynics also argue that “detached concern,”
long considered a happy description for the
relationship physicians should seek with their
patients, refers to concern that students bring
to their formal medical education, where fac-
ulty members then teach them detachment. I
partially disagree. Yes, young stu-
dents come bearing a large supply
of willing altruism, but some of it
must be characterized as too na-
ive, not realistic. The world’s a
tough place and gradually one un-
derstands that inflicting kindness
on people often won’t succeed.
Taking care of the sick some-
times means curing, but always should mean
attempting to reduce suffering. Technical com-
petence is a must. And a world that includes,
inevitably, material shortages of everything
(except perhaps death and taxes) must add
some sharp edges to what might otherwise
remain a ball of warm fuzzies, comfy but inef-
fectual. Attaining the happy balance, as with so
many things, is what’s crucial.
Our focus is
thus trans-
formed from
helping a
sufferer to
making a sale.
As our attention fastens increasingly on cost
containment and a hostile legal-regulatory cli-
mate, it becomes even harder to avoid the
depersonalization that has been increasing in
the medical world. But a recent advertisement
makes a good point: “The last word in managed
care is still care.” It also dares to suggest,
however, that “managed care” might more hon-
estly be termed “managed cost,” since the con-
cerns often lie more with cost than care. But
that’s the cynics talking again.
The Latin origin of the word “patient” de-
rives from the verb “to suffer.” If we would
mitigate suffering effectively enough, the suf-
ferer would cease being a patient; but true to
say, doctors, collectively, will never be out of
work, because there’s a potentially infinite sup-
ply of suffering. Whenever medical
practices becomes more a business
enterprise than a public service,
the “patient” becomes a “cus-
tomer”; our focus is thus trans-
formed from helping a sufferer to
making a sale. The language we use
not only reflects our reality but
shapes it.
A bumper-sticker recently urged me to “com-
mit random acts of kindness.” It’s a variation of
“inflict kindness.” It’s also good counsel. Such
acts should be, I submit, not only random
regarding time, place and recipient, but should
be largely spontaneous. The joy, or at least the
satisfaction they yield will tend to make one
commit other such acts. Our world can always
use more of them. H3
Richard Caplan, MD
Iowa Medicine Volume 85 / 3 March 1995 131
Iowa [Medicine
Classified Advertising
Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: family
practice, invasive cardiology, oncology/
hematology, orthopedic surgery and general
internal medicine practice. The Mankato
Clinic is a 65-doctor multispecialty group
practice in south central Minnesota with a
trade area population of +250,000. Guaran-
teed salary first year, incentive thereafter with
full range of benefits and liberal time off. For
more information, call Roger Greenwald,
Executive Vice President, at 507/389-8500 or
Anthony C. Jaspers, President, at 507/726-
2136 or write 1230 East Main Street, P.O. Box
8674, Mankato, Minnesota 56002-8674.
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Marshalltown, Iowa
Best of both worlds — rural small group at-
mosphere, urban large group amenities. Seek-
ing quality emergency physicians interested
in stellar emergency medicine practice. Full-
time and regular part-time. 12K volume/ 12-
hour shifts. Democratic group, highly com-
petitive compensation, paid St. Paul mal-
practice with unlimited tail, excellent benefit
package/bonuses for full-time. Numerous
other Iowa locales. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021; 800/729-
7813 or 515/964-2772.
General Surgeon, Creston, Iowa — An opening
for a third BC/BE surgeon in a very busy
general surgery practice located 1 hour from
Des Moines, Iowa. Two-surgeon department,
expanding to 3 due to work load, is associated
with 13 other physicians. Salary and benefit
package very lucrative including moving
expenses and full partnership within 1 to 2
years with limited call duty. Country living in
a community of 9,000 with excellent educa-
tional system, recreation, low crime rate and
lifestyle not found in metro areas. Contact
Mike Brentnall, 515/782-2131 or send CV to
Creston Medical Clinic, PC, 526 New York
Avenue, Creston, Iowa 50801.
Locum Tenens
Emergency Medicine
Seeking quality physicians interested in
emergency medicine practice or primary
care locum tenens. Full-time and regu-
lar part-time. Numerous Iowa locales.
Democratic group, highly competitive
compensation, paid St. Paul malprac-
tice with unlimited tail, excellent ben-
efit package /bonuses to full-time phy-
sicians. Contact ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021.
Phone 1-800/729-7813 or515/964-2772.
Family Practice — Leading 300+ physician
group based in southwestern Wisconsin seeks
additional family practitioners for established
branch clinics in Wisconsin and Iowa.
Attractive group practices offer a professional
and stimulating environment with shared call
coverage, modern local hospitals, strong
specialty network and competitive compensa-
tion package. Practice settings vary from a
scenic college town to a picturesque Missis-
sippi River community. For details, call Mike
Krier at 1/800-243-4353.
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
General Faculty', Department of Family
Practice, University of Iowa College of
Medicine — The University of Iowa Department
of Family Practice offers full-time faculty
positions for residency-trained, ABFP certified
family physicians. Obstetric skills and
previous teaching experience highly desirable.
Additional faculty needed to address new
primary care initiatives. As a part of a full
academic department, responsibilities include
teaching, research and patient care. Well-
established, 24-resident program is university-
administered, community-based, and has
admissions at community and university
hospitals. A new model office facility is being
built. Well-established department with
special strengths in its clinical and behavioral
science faculty. As a “Big Ten” university
community, Iowa City is a great place to live.
Appointment and salary commensurate with
qualifications and experience. The University
of Iowa is an Equal Opportunity and Affirma-
tive Action employer. Women and minorities
are strongly encouraged to apply. Submit a
letter of interest and CV to Gerald J. Jogerst,
MD, Interim Department Head, Department of
Family Practice, 2149 Steindler Building, Iowa
City, Iowa 52242-1097; 319/335-8454.
Minneapolis, MN — Opportunities available for
BE/BC family practitioners with OB to join 6
person group. Western Minneapolis suburb.
No practice buy-in required. Excellent salary
and benefits. Please send CV or call Nancy
Borgstrom, Aspen Medical Group, 1021
Bandana Boulevard East #200, St. Paul,
Minnesota 55108, 612/642-2779 or fax 612/
642-9441. EOE.
Primary Care Physicians and Subspecialists —
Are being sought for a variety of group
practices located throughout the upper
Midwest and New York state. Choose from
metropolitan cities, college towns, popular
resort communities or traditional rural
distinctions. This month, opportunities
available for physicians specializing in family
practice, internal medicine, pediatrics,
occupational medicine, hematology/oncology
and nephrology. New opportunities monthly!
For all of the facts, call 800/243-4353 or write
to Strelcheck and Associates, 10624 North
Port Washington Road, Mequon, Wisconsin
53092.
132 Iowa Medicine Volume 85/ 3 March 1995
CLASSIFIED ADVERTISING
LeMars , Iowa
Seeking quality physicians to prac-
tice at a 4300 average volume ER.
Director and staff positions. Full
and regular part-time. Democratic
group, highly competitive compen-
sation, paid St. Paul malpractice with
unlimited tail, excellent benefit pack-
age/bonuses to full-time physicians.
ACUTE CARE, INC., P.O. Box 515,
Ankeny, Iowa 50021; phone 800/
729-7813.
I Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
i an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
fi family oriented community 40 miles northeast
u of Des Moines. We have a beautiful new
ii facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
Time For a Move?— BC/BE FP, IM, OB/GYN,
PEDS. Our promise — We’ll save you valuable
time by calling every hospital, group and ad in
your desired market. You’ll know every job
within 20 days. We track every community in
the country, including over 2000 rural
locations. Cedar Rapids, Des Moines, Quad
Cities, Kansas City, Boston, Chicago, India-
napolis, many more. New openings daily — call
now for details! The Curare Group, Inc., M-F
9am-8pm, Sat 1-5 pm EST. 800/880-2028, Fax
812/331-0659.
Emergency Medicine, Council Bluffs, Iowa —
Opening available for qualified physician to
join group of emergency physicians. Training
and/or certification in primary care specialty
or emergency medicine. Flexible scheduling.
Newly remodeled emergency department.
Enjoy rural and urban atmosphere. Compen-
sation up to +8200K/year plus vacation. Write
Bluffs Emergency Care Services, PC, 933 East
Pierce Street, Council Bluffs, Iowa 51503; 712/
328-6111.
Internal Medicine, Carroll. Iowa — Outstand-
ing professional opportunity for an internal
medicine physician in a progressive, safe and
clean community of 10,000. This opportunity
is available for either practicing internal
medicine physician, or the internal medicine
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more informtion, call Randy Simmons, vice
president, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
Sioux City — An excellent position is available
for a BC/BE family practice physician in a new
community health center. A full range of
family practice medicine is needed in a
community that is very supportive of the
center. Sioux City is a great place to raise a
family and has excellent public and parochial
school systems, a community college, 2 liberal
arts colleges, a graduate center, 2 excellent
medical centers, a Residency Training
Program (family practice), etc. The center
offers a competitive compensation and benefit
package, paid malpractice, etc. FEDERAL
LOAN REPAYMENT PROGRAM AVAILABLE.
For more information write Jeff Hackett,
Executive Director, Siouxland Community
Health Center, PO Box 2118, Sioux City,
Iowa 51104-0118 or call 712/252-2477.
Not Just Another Recruitment Ad — Opportu-
nities at North Memorial-owned and affiliated
clinics will give you a shot of adrenaline
because we practice in a care management
environment that FPs, IMs and OB/GYNs
thrive on. Guide your patients through their
entire care process at one of our 25 clinics in
urban or semi-rural Minneapolis locations.
Plus, become eligible for 815,000 on start date.
Interested BC/BE MDs, call 1/800-275-4790 or
fax CV to 612/520-1564.
Family Practice, Carroll, Iowa — Outstanding
professional opportunity for family practice
physicians in a progressive, safe and clean
community of 10,000. These opportunities
are available for either experienced family
practice physicians, or the family practice
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more information, call Randy Simmons, Vice
President, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
Lighted Slide Storage System — Stores 1000+
slides on illuminated racks. Find any slide
quickly and easily. Free catalog 800/950-7775.
Boone , Iowa
Seeking a quality emergency physician
interested in a stellar emergency medi-
cine practice. Full and regular part-
time position available. Democratic
group, paid St. Paul malpractice with
unlimited tail. Excellent benefit pack-
age/bonuses to full-time physicians.
Average volume with above-average
compensation. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021;
phone 800/729-7813.
Faculty position — For a well-established
community-based family practice program in
Davenport, Iowa, affiliated with the University
of Iowa. Seeking board certified family
physician to join 3 other full-time family
physicians, a clinical pharmacist, a behavioral
science coordinator and our program
administrator in a team approach to practicing
and teaching the full range of family medicine.
Our program emphasizes a true individual
family practice experience for each resident in
parallel to subspecialty experience with
enthusiastic community preceptors. Faculty is
encouraged to develop individual special
interests and the chance to share their
experience with physicians in training.
Davenport is part of the Quad Cities, a large
metropolitan area centered in the Mississippi
Valley on the Illinois and Iowa border.
Excellent school system. Experience in
practice or teaching valuable but not required.
Obstetrics required. Excellent benefit
package, competitive salary commensurate
with experience. Contact Monte L. Skaufle,
MD, Director, Quad Cities Genesis Family
Practice Residency Program, 516 W. 35th
Street, Davenport, Iowa 52806.
Advertising Rates and Data
Regular classified advertising sells for 82.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for 825 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85/ 3 March 1995 133
DOCTORS' DAY
MARCH 30
HAPPY
DOCTORS’ DAY
Doctors' Day originated in 1933 in Georgia by Mrs.
Charles Almond. Mrs. Almond was inspired by the
dedication and outstanding achievements of physicians.
March 30 was chosen as the date for observing Doctors'
Day because it commemorates one of the greatest discover-
ies in medicine. On March 30, 1842, Dr. Crawford Long
first used ether as an anesthetic in a surgical operation
thereby providing mankind with freedom from pain and
suffering during surgery.
|||||\ The first Doctors' Day commemoration in Iowa was in
1957. The purpose of Doctors' Day is to honor members of
the medical profession. The true objective of the observance
is to pay tribute to the physician for services rendered in
the community.
On March 30, 1958, a resolution commemorating Doc-
tors' Day was adopted by the United States House of
Representatives. On October 30, 1990, President George Bush signed a joint resolution into law
designating March 30 as National Doctors' Day.
The red carnation is the official symbol of Doctors' Day. The Iowa Medical Society Alliance takes
great pride in saluting our doctors that serve the community, not only on Doctors' Day, but everyday.
V2.
A MEDICAL ALLIANCE PROJECT
AN ARMY SCHOLARSHIP COULD
HELP YOU THROUGH MEDICAL SCHOOL
The U.S. Army Health Professions
Scholarship Program offers a unique
opportunity for financial support to med-
ical or osteopathy students. Financial
support includes tuition, books, and
other expenses required in a particular
course.
For information concerning eligibil-
ity, pay, service obligation and application
procedure, contact the Army Medical
Department Personnel Counselor:
CPT. RHONDA HOWARD 1-800-347-2633
ARMY MEDICINE. BE ALL YOU CAN BE.
Merrill, Wisconsin
Family Practice
When you join a practice in Merrill, Wisconsin, you'll be
close to what is important to you: your practice and your
H family.
|| A practice in Merrill, Wisconsin means you're in the
middle of safe, thriving areas offering diverse commercial
; interests, cultural variety, all-season recreation, and highly-
|| rated school systems. You will receive a wide range of
|| benefits including an excellent compensation package while
practicing in a smaller, personalized environment.
We offer a lot and would like to also tell you what we don’t
|| offer: high cost of living, pollution, crime,
congestion, and traffic.
For more information on Merrill, Wisconsin, please contact:
Sam Holte, 1-800-766-7765.
FAX: (715) 847-2984. an
Wausau Regional Health-
care, Inc., 3000 Westhill Dr., IVsusao Regional Health Care, Inc.
' Suite 202, Wausau, Wiscon-
sin 54401.
LA CROSSE
WISCONSIN
• Live in beautiful Mississippi River Valley.
• Work with high quality colleagues in
growing multispecialty group (70 physicians).
• Competitive income/benefits.
SPECIALISTS NEEDED
Cardiology (Non-Invasive)
Critical Care/Pulmonary Medicine
Dermatology
Emergency Medicine
Family Practice
Internal Medicine
Neurology
Occupational Medicine
Orthopedic Surgery
Pediatrics
Urology
Send CV to: P. Stephen Shultz, M.D.
SKEMP CLINIC
800 West Avenue South
La Crosse, Wisconsin 54601
Fax 608/791-9898 or
Phone 608/791-9844, ext. 6329
You'll know
your career is on the rise
When m mmmm
...You customize your practice to
your interests. ..You receive productivity
based compensation with excellent 1st year
income guarantee. ..Consolidated organiza-
tion of our 50+ physician multispecialty prac-
tice frees you from both office management
and buy-in costs.. .Our comprehensive ben-
efits give you at least 5 weeks vacation/CME
time, malpractice, health, life, disability and
dental insurances, and $3750 CME
allowance. ..You join The Monroe Clinic— a
consolidated outpatient and inpatient
healthcare facility combining a new 1 14,000
sq.ft, clinic and adjoining 140-bed acute care
hospital with 24 hr. ER coverage serving
south central Wl and northern IL. We have
openings for BGBE physicians in:
• Family Practice
• OB/CYN
• Cardiology (non-invasive)
• Outpatient Psychiatry
• Orthopedic Surgery
• Pulmonology
• Dermatology
The Monroe Clinic
A proud caring tradition
You'll like the friendly
neighbors and
neighborhoods in four-
season Monroe,
Wisconsin, a family-
centered rural
community of 10,000
located just one hour
from Madison, Wl,
Dubuque, IA, and
Rockford, IL...and two
hours from Chicago
and Milwaukee. We
enjoy excellent schools,
a thriving economy,
solid values, an
abundance of parks
and recreation centers,
popular entertainment
and shopping facilities,
and easy access to
nearby universities.
For more information
write or call: Physician
Staffing Specialist,
THE MONROE CLINIC,
SI 5 22nd Ave„
Monroe, Wl 53566.
800-373-2564. Or fax
resume to: 6081328-
8269. EOE.
Unique
Surgical
Opportunity
Estherville, Iowa (population 7,500) is
seeking a general surgeon. Northwest
Iowa location in the Lakes Region with
outstanding outdoor recreation. Six re-
ferring family practice physicians. Mini-
mal managed care. For more information
contact:
Tom Nordwick, CEO
Holy Family Hospital
826 North 8th Street
Estherville, Iowa 51334-1598
712/362-2631
Iowa|Medicine
Professional Listing
Allergy
Emergency Medicine
John A. Caffrey, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
K.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatrie and Adult Allergy, PC
Veljko K. Zivkovich, MD
Robert A. Column, MI)
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1*260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Robert J. .Barry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Bligard, MD, FAAD
James D. Bunker, MD, FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Bragc, MD
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gervich, MD
Daniel .1. Sehroeder, MD
Ravi K. Vemuri, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Internal Medicine
Fort Dodge Medical Center, PC
Cardiology >
Samir G. Artoul, Ml), FICC
515/574-6840
Gastroenterology
Kenneth \V. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MD, ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology1
Andrew C. Peterson, MI)
Laurence S. Krain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBIIS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lomorgese, MD
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
llosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
136 Iowa Medicine Volume 85/3 March 1995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Havne, MD
Thomas A. Carlstrom, MD
David J. Boarini, MD
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MD
S. Randv Winston, MI)
Douglas R. Koontz, MD
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad 1). Abemathey, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell H. Watt, MD
John M. Graether, MD
Gilbert W. Harris, MD
James A. Davison, MD
Norman F. Woodlief, MD
Eric W. Bligard, MD
David D. Saggau, MD
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert D. Whinery, MD
Stephen II. Wolken, MD
Robert B, Goffstein, MD
Lyse S. Stmad, MD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MD
Randall S. Brenton, MI)
James L. Dummctt, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Iowa Orthopaedic Center, PC
Marvin H. Dubansky, MD
Marshall Flapan, MD
Sinesio Misol, MD
Joshua I). Kimelman, DO
Timothy G. Kenney, MI)
Lynn M. Lindaman, MD
Jeffrey M. Farber, MD
Kyle S. Galles, MD
Scott A. Meyer, MD
Cassini M. Igram, MI)
Donna J. Bahls, MD
Jill R. Meilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MD
Marshall C. Greiman, Ml)
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Hill, MD
Daniel J. Blum, MI)
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery , Head
and Neck Surgery
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: S10.00 first
3 lines; 52.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85/ 3 March 1995 137
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MD
Eugene Peterson, MD
Richard B. Merrick, MI)
Peter V. Bocsen, MD
Robert R. Updegraff, MD
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neck
Surgery, PC
Thomas .1. Benda, Sr., MD
James W. White, Ml)
Craig C. Herther, MD
Thomas .1. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MD
Guy E. McFarland, MD
Thomas F. Viner, MI)
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery’
Robert G. Sinks, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery’
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
Janies R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Perinatology
I)es Moines Perinatal Center, PC
Neil T. Mandsager, MI)
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice 1). Schncll, Ml)
Farccduddin Ahmed. MI)
Arthur B. Searlc, MD
Bogdan E. Krysztofiak, MD
Rehabilitation Medicine Associates
William I). dcGravellcs, Jr., MI)
Charles F. Dcnhart, MI)
Marvin M. Hurd, MD
William C. Koenig, Jr., MD
Karen Kicnker, MD
Todd C. Troll, MI)
Fori A. Sapp, MD
Younker Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MI)
Steven G. Berry. MD
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matysik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary Diseases
Surgery
Wendell Downing, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Fort Dodge Medical Center, PC
Ralph F. Woodard, MD, FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Advertising Index
Bemie Lowe & Associates 126
Blue Cross Blue Shield 130
Dale Clark Prosthetics 125
Hawkeye Medical Supply 118
Holy Family Hospital 135
IMGMA 108
IMS Services 114
Josephs Ill
Medical Protective Company 139
Medical Records
Assistance Services 116
Mercy Hospital Medical Center 106
MMIC 140
Monroe Clinic 135
Skemp Clinic 135
Throckmorton Surgical Society' 102
U.S. Air Force 120
U.S. Army 134
Wausau Regional Health Care 135
138 Iowa Medicine Volume 85/3 March 1 995
IowalMedicine
THE PRESIDENT COMMENTS
Helping our patients
and our communities
Help for a medical student who needs fi-
nancial aid to get through those last two
years when the end still seems so far
away. A teen crisis Careline card for a high
school student with failing grades and an abu-
sive parent. These are examples of situations
where Iowa physicians have picked up the yoke
to help move the wagon. Iowa physicians —
through the IMS Education Fund — are helping
make the load lighter. Medical students borrow
money from the fund, pay a reasonable interest
and — as they start earning — pay back the funds
to enable other students to borrow. Only a
handful of students over 25 years has defaulted.
The Iowa Medical Society Education Fund,
which exists because of contributions from
Iowa physicians, is the largest source of private
money to Iowa medical students.
Eight hundred and fifty three
student loans have been made
since the inception of the Educa-
tion Fund. In 1994-95, $265,000
has been allocated. The IMS Edu-
cation Fund, which is also involved
in physician education projects,
helped support the January and
February issues of Iowa Medicine, which were
devoted to domestic violence.
Many requests are made to the Iowa Medical
Society Education Fund for worthwhile projects.
Some projects provide opportunities to pro-
mote our association and assist our patients
that would not otherwise be available. This
year a committee on fund-raising activities was
appointed. It is comprised of past presidents of
our medical society. This committee will con-
sider ways to increase the amount of contribu-
tions to the IMS Education Fund as well as the
number of contributors. The first meeting was
held January 10, chaired by Dr. Paul Seebohm.
Other past presidents who attended were Dr.
Donald Rodawig, Dr. John Tyrrell and Dr. Den-
nis Walter.
Some recommendations were to establish a
short term financial goal, develop appropriate
brochures/articles, target the audience, pro-
vide recognitions of various categories of givers
and develop accurate information on ways to
contribute to the Fund.
Through the IMS Education Fund, physi-
cians have a vehicle to promote medicine in
Iowa, gain a positive image and help our pa-
tients and communities in a posi-
tive way. We can do more united
than we can alone. Please help
your organization and yourself by
contributing to the IMS Education
Fund. [Cj]
Iowa
physicians
are helping
make the
load
lighter.
James White, MD
Iowa Medicine Volume 85 / 4 April 1995 147
Iowa I Medicine
IMS Update
AT A GLANCE
Don’t forget to complete
and return your survey
on general format and
location of the IMS
House of Delegates meet-
ing. The survey was
enclosed with a letter
regarding 1995 IMS elec-
tions which was mailed
in early March to all IMS
members. The survey
can be returned by mail
or by fax, 515/223-8420.
•
Two experts on telemedi-
cine applications will be
speaking at the final day
of the Iowa Hospital
Association Annual
Meeting Thursday, April
27 at the Des Moines
Marriott. There will also
be a demonstration of
the virtual hospital.
Physicians are welcome
to attend the plenary ses-
sions which begin at
8:30 a.m. For more
information, call Becky
Anthony at the IHA,
515/288-1955.
House of Delegates weekend April 28-30
The focus will he on IMS policy on health
care issues and developments in technology
and treatment April 28-30 when Iowa physi-
cians gather for the Iowa Medical Society’s
1995 House of Delegates and Scientific
Session at the Marriott Hotel.
The Scientific Session will begin at 8:00
a.m. Friday and will conclude with a Sunday
morning panel discussion of domestic vio-
lence. Dr. Richard Corlin, vice speaker of the
AMA House of Delegates, will be a special
guest for the weekend’s activities.
The House of Delegates will begin deliber-
ations Saturday morning at 8:30 a.m. An ori-
entation session for new delegates will be
held at 7:30 a.m. The concluding session of
the House will begin at 10 a.m. Sunday and
will include election of officers.
Policy resolutions cover many subjects
As of press time, the following policy reso-
lutions had been received:
1. Community Health Management Information
System (CIIMIS) (Introduced by District VIII) —
Asks that the IMS recommend to the CHMIS
Governing Board that Blue Cross/Blue Shield he
denied any future hid to become the state data
repository' for the CHMIS network.
2. Administrative Support for Specialty
Societies (Introduced by District VIII) — Asks
that the IMS, via its wholly-owned subsidiary
IMS Services, market its capability’ to provide
administrative services to state specialty societies
on a fee-for-serviee basis.
3. Futile Care (Introduced by Districts X &
XI) — Asks that IMS delegates to the AMA
strongly encourage AMA to develop community
guidelines to determine when care is appropriate
at the end of life while maintaining patient digni-
ty and physician integrity.
4. Abolishment of GPCIs (Introduced by
Districts X & XI) — Asks the IMS to send a reso-
lution to the 1995 AMA House of Delegates
requesting them to submit legislation providing
for elimination of or more fairly calculated
Geographic Practice Cost Indices.
5. Pediatric/Adolescent Morbidity and Mortal-
ity due to Firearms (Introduced by Districts X &
XI) — Asks the IMS to establish a task force on
violence intervention and support legislation
which reduces the availability of guns to children.
6. IMS Annual Meeting Date (Introduced by
Districts X & XI) — Asks that the date of the
annual IMS House of Delegates be set back to
March.
7. Standing Committee on Personal/Family
Violence (Introduced by Districts X & XI) — Asks
the IMS to establish a standing committee on
family/domestie violence and introduce unam-
biguous legislation regarding criminal domestic
violence reporting requirements and the medical
hospital law enforcement investigative coopera-
tion process.
Specialty Society Update
The IMGMA Spring Meeting will be May 3-5 at the Des
Moines Marriott. Board and committee chairs partici-
pated in a strategic planning session March 3-4. The
second Management Education Program (MEP) will
begin in May rather than March. More information will
be mailed to IMS members soon. This is a great
opportunity to learn administrative principles which
will aid physicians in the managed care environment.
The Iowa Psychiatric Society Spring Meeting will be at
the Des Moines Marriott April 7.
Newly elected to the American College of Cardiology,
Iowa Chapter — Phillip Habak, MD, president-elect;
Todd Langager, MD, secretary-treasurer. Council
members are: Steven Phillips, MD; David Lemon, MD;
Ellen Gordon, MD and Richard Menning, MD.
The Iowa Society of Anesthesiologists Spring Meeting
was held April 1 at the Des Moines Convention Center.
Norig Ellison, MD, president-elect of the American
Society of Anesthesiologists, was keynote speaker.
The Oncology Society board meeting will be April 26 at
the University of Iowa Hospitals and Clinics.
Coma stimulation and post-polio case presentations
were discussed at the Iowa Society of Rehabilitation
Medicine Spring Meeting April 7.
148 Iowa Medicine Volume 85 / 4 April 1995
8. Inappropriate Requests for Physician DEA
Registration Numbers (Introduced by District II) —
Asks the IMS to remind physicians that the Drug
Enforcement Agency registration number is
intended to regulate the prescription of con-
trolled substances and encourage physicians to
report inappropriate requests to the Board of
Pharmacy Examiners.
9. IMPAC Representation for Residents,
Students (Introduced by District II) — Asks that
the IMS Board of Trustees appoint a resident and
a medical student to serve on the Iowa Medical
Political Action Committee Board.
10. IIIV Testing, AIDS Prevention (Intro-
duced by District II) — Asks the IMS to support
a number of initiatives regarding HIV and AIDS.
11. Support Program for Physicians Sued for
Malpractice (Introduced by District I) — Asks
that the IMS develop a model support program
for physicians being sued, and submit a resolu-
tion to the AMA asking for resources to support
development of such a program.
12. Pension Protection (Introduced by District
III) — Asks the IMS to adopt a policy that pen-
sion assets of federally qualified pensions be
exempt from civil liability awards including mal-
practice suits and pursue legislation to that
effect.
These resolutions and any others received
before the meeting will be considered by ref-
erence committees before being presented to
the full House of Delegates on Sunday.
Reference committee deliberations will begin
Saturday, April 29 at 1 p.m.
Reference committee hearings give IMS
delegates and other physicians the opportu-
nity to comment on resolutions before they
are submitted for House action on Sunday.
Supplemental reports to House
The House of Delegates will also receive
supplemental reports from the Board of
Trustees and the IMS Committee on CIIMIS.
The Board report will discuss finances, Iowa
Medicine, specialty society representation in
the House of Delegates plus several articles
and bylaws changes.
The IMS CHMIS Committee met April 4
and will report to the House on the activities
of the CHMIS Governing Board and Advisory
Committees and on a proposed IMS state-
ment of principles.
Special events
•IMPAC will hold a reception Friday
evening from 6:00 - 9:00 p.m. at the Marriott.
•David Werner, a political satirist from
Washington, DC will be the entertainment at
the Saturday evening banquet. Newly-elected
U.S. Congressman Greg Ganske, MD will be a
special guest at the banquet.
Candidates for IMS offices named
The IMS Nominating Committee has
assembled the following candidate slate for
1995-96 elections. The slate will be formally
presented to the IMS House of Delegates on
Saturday, April 29 and further nominations
will be accepted from the floor. Elections will
be held at the final House session Sunday.
Candidates for 1995-96 offices
President-elect (1-year term) — William McMillan, MD
Vice president (1-year term) — Hunter Fuerste, MD
and Sterling Laaveg, MD
Trustee (3-year term) — Siroos Shirazi, MD
Speaker, House of Delegates (1-year term) — Donald
Kahle, MD
Vice speaker, House of Delegates (1-year term) — Tom
Throckmorton, MD
AMA delegates (2-year terms, 2 will be elected) —
Clarkson Kelly, Jr., MD; and Daniel Youngblade, MD
AMA alternate delegates (2-year terms, 2 will be elected) —
Jeff Anderson, MD; Bernard Fallon, MD; Bryan Pechous,
MD; Askar Qalbani, MD; and Mir Waziri, MD
District Councilors (3-year terms)
District 1 — Robert Kent, MD
District VI — John Justin, MD
District IX — Jay Heitsman, MD
District XIII — Linda Her, MD CZ3
Focus on IMS Alliance
The Alliance began its year poised for change,
ready to meet challenges. We expected change to
come in the form of sweeping government mandates,
but it reached us in the form of forces driven by the
marketplace. Many have been dragged along; some
have been innovators.
This month brings us the annual meetings of the
House of Delegates for both the IMS and IMSA. As we
shift our focus, I encourage everyone to examine
their own involvement. Now, more than ever, it is
imperative that physicians and spouses become
“One Voice, One Choice” for medicine. We can let
change happen or make it happen. The choice is
ours.
Contributed by Barbara Bell, president, IMSA
Iowa Medicine Volume 85 / 4 April 1995 149
Iowa [Medicine
Futures
AT A GLANCE
President Clinton’s bud-
get was “kind” to
Medicare and Medicaid ,
but some Democrats
private ly complained
that it didn't go far
enough in recommend-
ing spending cuts, pri-
marily Medicare and
Medicaid. Senator Bill
Bradley, D-NJ, said he
was disappointed the
president's proposals
did not go further in
reducing the deficit.
In February, the IMS
Board of Trustees met
with officials of the
Iowa Hospital Associa-
tion. An IRS riding in
one non-profit hospital
case where a PHO was
limited to 20% physi-
cian representation was
discussed; both groups
agree that a true part-
nership would be 50-50.
IMS board members
meet every six months
with IHA officials.
•-
The IMS and IMGMA
were cosponsors of a
state data conference
April 6. More informa-
tion on the conference
will appear in next
month's Iowa Medicine.
Future at stake, say Iowa State economists
Two Iowa State University economists
have issued a press release in which they say
that our collective standard of living and eco-
nomic opportunity for the next generation
are at stake unless entitlement spending is
brought under control.
The economists, using what they call the
“inexorable laws of arithmetic and demo-
graphics”, say that a crisis point will arrive in
2001 when Medicare becomes insolvent. The
second will arrive in 2008 when the first of
the Baby Boom generation begin to retire.
By 2012, if the current tax and spending
policy is continued, Medicare, Medicaid,
Social Security and federal employee retire-
ment programs will consume all tax revenues
collected by the federal government.
The ISU economists say these predictions
could have an even greater impact for Iowans
since we have an older population.
“National tax cut plans of both parties are
politically popular but risk significant folly in
the long run,” say the economists.
Update on managed care developments
The American Medical Association makes
available to the IMS weekly information on
market trends in managed care. Following are
items from recent releases.
•There was a 16% increase in the number
of managed care plans during 1994, a 19%
increase in the number of PPOs and a 9%
Financing physician ventures
In the May Iowa Medicine, Steve DeNelsky,
senior financial consultant with Medical
Alliances in Alexandria, Virginia, will discuss
financing of physician managed care ven-
tures — options available and steps neces-
sary to obtain financing.
increase in managed care enrollment.
•Over 650 hospitals were involved in
mergers or acquisitions in 1994. In 1993, the
AHA recorded just 18 community hospital
mergers.
•A California Medical Association study
found for-profit IIMOs spend more money on
administration than not-for-profit IIMOs.
•Employer-owned primary care centers
may be the wave of the future. Delta Airlines,
Bethlehem Steel, Goodyear, RJ Reynolds and
John Deere have all built their own primary
care clinics. John Deere has announced plans
to develop a second John Deere Family
Health plan center in the Des Moines metro
area. The trend has been dubbed “backward
integration”.
•The number of employers using managed
care plans to funnel injured employees to
IIMOs has increased to almost 50%, up from
20% in 1991.
•Some health systems — including
Chicago’s Rush Presbyterian — have estab-
lished managed care colleges to educate pri-
mary care physicians on clinical practice
guidelines, outcomes measurement and other
key components of physician practice in a
managed care environment.
•Risk management experts are concerned
that, as providers consolidate, they are
neglecting outpatient liability issues. St. Paul
Fire and Marine reports that outpatient
surgery claims jumped from |15.1 million in
1992 to $8.7 million in 1993.
•According to US News and World Report, an
increasing number of physician specialists are
retraining to become primary care physicians.
AMA capital source program
The Wall Street Journal and other major
papers have carried stories describing the
AMA’s new Physicians Capital Source pro-
gram, which Iowa physicians learned of dur-
ing last October’s Futures conference in Des
Moines.
According to the Wall Street Journal, the
150 Iowa Medicine Volume 85/4 April 1 995
CURRENT ISSUES
program “will give doctors business skills and
introduce them to sources of capital so they
can compete against insurers and investor-
owned health maintenance organizations
dominating the health care landscape.”
Thomas Reardon, MD, AMA secretary-
treasurer, said the program is “a way for
physicians to preserve some of their autono-
my by forming their own networks and estab-
lishing their own destiny.”
For more information about the AMA
Physicians Capital Source program, call
800/AMA-1066.
Reform may revive in congress
Portions of last year’s health care bills,
including insurance reform, were gaining
support from Republican congressional lead-
ers. Newt Gingrich held out the prospect of
“building blocks” of reform going to President
Clinton’s desk as early as June if the presi-
dent and Democrats don’t try for anything
sweeping.
Senate Republican leader Bob Dole sup-
ports a series of relatively limited market-
based reforms. These would include portabil-
ity and protection for patients with pre-exist-
ing conditions.
In other developments in Congress, sup-
port appears to be growing for a complete
transformation of the Medicaid program to
give states much greater control of the sys-
tem. Thomas Bliley, House Commerce
Committee chairman, is calling for conver-
sion of Medicaid into a system of block grants
to the states.
In other developments:
•The AMA asked Congress to work on a
number of reforms, among them: changes in
Medicare, insurance and tort reform,
increased funding for medical education and
research and cutting government red tape.
Among possible Medicare changes — treating
benefits for affluent Americans as taxable
income and allow patients to opt out of
Medicare and join private health plans.
•Republican leaders of the House Ways
and Means Subcommittee on Health con-
firmed yesterday that affluent Medicare ben-
eficiaries are an early target in the hunt for
savings. E3
Who?
Abu.
Sky Plus® Travel Club is introducing
a special program exclusively for IMS
Association Members and their families.
What?
With the IMS/Sky Plus® Travel Club,
you save every time you travel. ..on air
fares, hotels, car rentals, and more.
Watch your mail for details
Or phone 1-800-723-8686
AND ASK FOR THE ASSOCIATION DESK
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Iowa Medicine Volume 85 / 4 April 1995 151
Iowa | Medicine
Legislative Affairs
Bills in the Iowa Legislature
AT A GLANCE
March 17 was the first legislative funnel
deadline. By this date, most bills must have
been approved by a committee in the house
of origin. Several IMS priority issues met this
deadline:
The Iowa Medical
Political Action Comm-
ittee (IMPAC) will hold a
reception on Friday
evening, April 28, at 6
p.m. at the Marriott
Hotel. The reception is
planned in conjunction
with the IMS Annual
Meeting.
•
The American Medical
A s soc iat ion l eg i slat iv e
agenda for the 104th
Congress includes the
following major initia-
tives: medical savings
accounts, regulatory
relief/CLIA, professional
liability reform. Medi-
care, the Patient Protec-
tion Act and antitrust
relief.
•
The 1995 Governor's
Conference on Aging
will be held May 1 7 and
18 at University Park
Holiday Inn in West Des
Moines. The IMS is a
cosponsor of the confer-
ence, entitled “Aging:
Celebrating a Lifetime of
Experience". For more
information, contact the
Iowa Dept, of Elder
Affairs, 515/281-5187.
Statute of Limitations — HF 394
I IF 394, reducing the extended statute of
limitations for minors, has been approved by
the House Economic Development Commit-
tee. There is considerable support in the
House; the future of the bill is uncertain in
the Senate. Contact with senators and repre-
sentatives is urgently needed if this bill is to
have a chance of passage. I IF 394 reduces the
statute of limitations for minors so that the
normal statute of limitations begins running
when a child reaches age six. This limit
allows a lawsuit for an alleged birth injury to
be filed until the child reaches age eight.
Statewide Trauma Plan — SF 118
The statewide trauma plan bill has passed
the Senate and is in the House Human
Resources Committee. SF 118, supported by
the IMS, establishes a mechanism to coordi-
nate trauma care through a trauma care des-
ignation system. Designations will be based
on self-reported information. No hospital will
be prevented from providing care for which it
is licensed.
Physicians of various specialties and hospi-
tals will be strongly represented on both the
governing body and the quality assurance
review committee. The plan was developed
by the Iowa Trauma Systems Development
Project Planning Consortium which was com-
posed of physicians, hospitals, EMS pro-
viders, nurses and representatives of the
Governor’s Traffic Safety Bureau and the
Iowa Department of Public Health.
Helmet Law— SF 224
SF 224 requiring motorcycle operators and
passengers to wear protective helmets has
Contacting Your Legislators
Telephone numbers during the session:
Senators 515/281-3371
Representatives 515/281-3221
Governor 515/281-5211
Write to them at:
STATEHOUSE
Des Moines, Iowa 50319
You may also contact your legislators at home
when the legislature is not in session. If you don’t
know who your legislator is or need your legisla-
tor’s home address and phone number, call Lyn
Durante of the IMS staff, 800/747-3070 or
515/223-1401.
been approved by the Human Resources
Committee. The IMS supports this bill and
encourages physicians to ask both Senators
and Representatives to vote for it. Support.
Tobacco — SF 203
The IMS/Tobacco Free Coalition bill has
been approved by the Senate Human
Resources Committee. It would require
restaurants with smoking areas to eliminate
transmission of tobacco smoke into non-
smoking areas, repeals the prohibition on
local governments enacting tobacco ordi-
nances which are stricter than state law, and
provides that the Department of Public
I Iealth would be responsible for adopting reg-
ulations to enforce the clean indoor air act.
Support.
Uniform Anatomical Gift Act — SF 117
SF 117, updating the state’s Uniform
Anatomical Gift Act, has been passed by the
Senate and approved by the House Human
Resources with some minor modifications.
Current law was passed in 1983; SF 1 17 mod-
ernizes the act and makes such changes as
allowing teenagers to sign organ donor cards
with the cosignature of a parent and provides
152 Iowa Medicine Volume 85 / 4 April 1995
CURRENT ISSUES
IMS/AMA POLICY ON CAPITAL
PUNISHMENT
A bill to reinstate capital punishment went
down to defeat in the Iowa Legislature. However,
it is possible the issue could be raised again at a
later date. For future reference, following is a
summary of IMS/AMA policy.
The AMA says a physician’s opinion on capital
punishment is “the personal moral decision of
the individual”, but that it is unethical for a
physician to participate in legally authorized exe-
cutions.
In its policy compendium updated last June, the
AMA says “a physician, a member of a profession
dedicated to preserving life when there is hope of
doing so, should not be a participant in a state
execution.”
Physician participation is clearly defined as an
action which would directly cause the death of
the condemned; or an action which would assist,
supervise or contribute to the ability of another
individual to directly cause the death of the con-
demned.
According to the AMA’s guidelines, physicians
should not monitor vital signs either on site or
remotely, attend or observe an execution as a
physician or render technical advice regarding
execution.
During the course of the 1995 legislature, IMS
representatives monitored capital punishment
proposals to ensure that physician participation
was not mandated.
recognition of intent to donate indicated on a
drivers license. The IMS supports this bill.
Prior Authorization for Prescription Drugs
The Department of Human Services has
recommended that prior authorization he
required for use of any brand-name prescrip-
tion drug for which a generic equivalent is
available. To receive authorization for the
brand name, documentation of treatment
failure with the generic would be required.
The proposal is a cost cutting measure.
Physicians already widely use generics for
Medicaid patients (67% of the time when a
generic is available). The IMS supports the
use of generic drugs if the treating physician
determines it is appropriate for the patient.
In place of the prior authorization require-
ment, IMS recommends the Medicaid pro-
gram — through the Drug Utilization Review
Commission — focus on providing education
and information to physicians about the
availability and appropriate use of generic
drugs.
Managed Care
The IMS is continuing to negotiate with
third party payers to voluntarily include pro-
visions of the AMA’s Patient Protection Act in
their managed care plans.
Negotiations are focusing on providing reg-
ular opportunities for all physicians to apply
to a plan, letting physicians know the criteria
for selection and due process in the case of
rejection or termination from the plan.
Several meetings have been held with payer
representatives.
Any Willing Provider
Several different any willing provider bills
have been introduced at the request of
optometrists and chiropractors. USB 233
requires health care plans with limited
provider networks to allow direct access to
providers who “utilize differential diagnosis
and physical examinations to determine
human ailments”. Access to specialist physi-
cians may be limited. The IMS opposes these
bills.
PA Rules
A new draft of administrative rules has
been proposed by the Board of Physician
Assistant Examiners relating to practice and
supervision requirements. The IMS is review-
ing the draft. The IMS was very concerned
about the previous version of the rules
because it significantly reduced require-
ments for supervision and experience for PAs
who practice in remote clinics without a
physician on site.
Legislative Schedule
April 7: Final date for Senate bills to be
reported out of House committees and House
bills out of Senate committees. (Certain bills
are exempt.)
April 17: Only unfinished business, confer-
ence committee reports and exempt bills
may be considered.
April 28: 110th day of session. Adjourn-
ment likely within a week. E3
Iowa Medicine Volume 85/4
\pril 1995 153
Iowa Medicine
Medical Economics
Medicare B claims system change CHMIS activities update
AT A GLANCE
A recent story in the
Boston Globe said the
number of residency
programs teaching how
to perform abortions is
dropping. In 1975,
26.3% of all programs
routinely offered train-
ing in first trimester
abortions. By 1991, the
figure had dropped by
more than one half.
•
As much as 97% of non-
insulin diabetes, up to
70% of heart disease,
11% of breast cancer
and 10% of colon cancer
in overweight Ameri-
cans can be attributed
to excess weight, accor-
ding to C. Everett /Coop,
former surgeon general.
Obesity is a “serious
disease ” that con-
tributes to more than
300,000 deaths per year,
he says.
On April 1, Blue Cross and Blue Shield,
Iowa’s Medicare carrier, changed to a claims
processing system called Multi-Carrier
System (MCS). The system does not change
Medicare rules or reimbursement. Physicians
should continue to report services as they
have in the past.
The system will not affect processing of
electronic or paper claims (80% of claims are
electronic); physicians arc asked to submit
claims as usual.
(However, according to the Medicare carri-
er, psychiatrists will find that the Provider
Remittance Advice docs not show the psychi-
atric deduction.)
The most obvious change will be a com-
pletely different provider remittance notice.
During these initial weeks of transition,
please watch your claims payments and
report incorrect payments to the Medicare
carrier immediately.
A special Medicare Info was sent to all
providers in mid-March containing complete
details on the transition to the new system.
If you experience problems with the new
system, please contact Medicare at the usual
numbers or Mary Reinsmoen at the IMS,
800/747-3070.
Antitrust predictions
Antitrust relief for physicians who wish to
compete in the new marketplace is a top pri-
ority of the American Medical Association,
but some experts predict that physicians can
expect no changes in antitrust rules.
The AMA argues that physicians need
more leverage to bargain with hospitals and
IIMOs and to make it easier to for doctors to
bargain together and set up their own net-
works.
However, according to the Kiplinger
Newsletter, antitrust relief is “staunchly
opposed” by hospitals, IIMOs and nurses.
The Community Health Management
Information System (CIIMIS) Governing
Board is continuing to meet monthly to work
out policy and procedural issues to imple-
ment Phase I of CHMIS in Iowa.
On July 1, 1996, all health care providers
must submit claims electronically using a
standard claim format; all payors will be
required to accept the standard format. Many
details regarding how the CIIMIS will work
have yet to be determined by the Governing
Board and five advisory committees.
The IMS has at least one member physi-
cian on each of these five advisory commit-
tees and two on the Governing Board.
As of press time, the main agenda item for
the Governing Board was the financing of the
CIIMIS. Also, the Data Advisory Committee
had completed a recommended list of data ele-
ments which could he collected from the
IICFA-1500 and UB-92 forms for the CIIMIS
data base. This list of data elements will now go
to the CIIMIS Governing Board for approval.
The Ethics and Confidentiality Advisory
Committee is formulating recommendations
on who will have access to data collected
through the CIIMIS and is reportedly taking a
conservative approach regarding “qualified
users”.
The Technical Advisory Committee is
working to develop criteria to certify CHMIS
networks in Iowa. They will also work with a
consultant to develop the request for propos-
al (RFP) for the repository contract.
The Iowa Medical Society’s CIIMIS
Committee planned to meet early this month
to finalize recommendations on IMS CIIMIS
policy. The committee will send a supple-
mental report to the House of Delegates at the
end of this month. This report will include a
proposal for a comprehensive IMS CIIMIS
policy. This policy will represent the IMS
position and will guide physician and staff
efforts throughout the creation and imple-
mentation of CIIMIS.
154 Iowa Medicine Volume 85 / 4 April 1995
CURRENT ISSUES
Current IMS CHMIS policy, approved by
the IMS Executive Council in 1993, says the
IMS favors electronic billing through a
CIIMIS but opposes creation of a central
repository to collect and disseminate infor-
mation from patients’ medical records.
According to the IMS position statement,
the CIIMIS as proposed, “has the potential to
reduce administrative costs, increase the effi-
ciency of claims submission and payment
and collect needed information on health
care costs, utilization and quality. The IMS
supports collection, analysis and dissemina-
tion of data on health care charges, utiliza-
tion and quality using information from the
insurance claim form.”
IMS staff are available to give a special pro-
gram on CIIMIS to any group of member
physicians. To schedule a program, call Barb
Heck, 515/223-1401 or 800/747-3070.
Vaccine for Children program
The Iowa Department of Public Health
(DPII) is ready to begin enrollment of
providers in the Vaccines for Children (VFC)
program. Implementation of the program is
anticipated June 1, 1995.
This program will replace the current
Medicaid Vaccine Replacement Program. The
Vaccine Replacement Program will be phased
out in the months following implementation
of the VFC program.
The VFC program was scheduled to begin
October 1, 1994 for public and private sector
providers. Disbandment of the national
Vaccine Distribution Center forced the delay
of the private sector implementation.
The DPII is currently seeking bids from
pharmaceutical distributors for private sector
providers. Implementation of the program is
provisional providing a pharmaceutical dis-
tributor is selected.
Physicians will be receiving information on
the VFC program from the DPII and are
encouraged to enroll as soon as possible to
allow for processing and delivery of vaccines
during the month of June. For more informa-
tion, call Don Callaghan at 515/281-7301 or
Becky Roorda at the IMS, 800/747-3070. [El
In the 1994 elections, IMPAC contributed over $66,000 to 114 candidates running for state
office. IMPAC contributed to 105 winners for a 92% success rate. Obviously, contributions from
Iowa physicians were well spent.
Here’s where
the real
battles are
being
fought
But we cannot stop there. The 1996 elections are just around the comer. We cannot afford to
let the interest of medicine be overshadowed by the banter of political rhetoric. The strides
made by IMPAC in 1994 must be sus-
tained through 1996 if Iowa physicians
are to be heard by their lawmakers.
If doctors abdicate responsibility to par-
ticipate in the political process, it is
certain that non-physician groups will
take our place. They have already be-
gun their fund-raising and grass roots
work for 1996 and we cannot afford to
fall behind now.
The time has come to step forward and
be heard through a strong IMPAC.
Join IMI'Af’ today!
Iowa Medicine Volume 85 / 4 April 1995 155
Iowa | Medicine
Practice Management
AT A GLANCE
Medicare changed to a
claims processing sys-
tem called MCS (Multi-
Carrier System) on
April 1. The system does
not change Medicare
rules, but there will be a
completely different pro-
vider remittance notice.
For additional details,
see this month’s Medical
Econo m ics sectio n .
•
On July 1, 1996, all
Iowa physicians will be
required to submit
c l a i m s electronical ly
through the Cl IMIS sys-
tem and all payers will
be required to accept a
standard electronic for-
mat. If you want to
know more about
CHMIS and what it
means for Iowa physi-
cians’ offices, call Dean
Gillaspey or Barbara
Heck at IMS headquar-
ters, 515/223-1401 or
800/747-3070.
Coding extravaganza this month
If you want answers to tough questions on
CPT, ICD-9 and IICPCS coding, the Iowa
Medical Society and IMS Services can help.
On Tuesday, Wednesday and Thursday, April
18, 19 and 20, there will he a coding extrava-
ganza at the Best Western Des Moines
International.
Nationally known coding expert Nancy
Maguire will teach the seminars. There will
be seminars on pediatric coding, surgical cod-
ing, primary care coding, orthopedic surgery,
neurosurgery and ENT coding.
If you want to come to the seminar and
would like to stay overnight, a block of rooms
has been reserved at a special rate of §52 per
night. For reservations, call the hotel directly
at 515/287-6464.
For more information or to register, call Mary
Reinsmoen at IMS Services, 800/728-5398.
Tuberculosis procedures
Does your office have a written policy per-
taining to employees or patients with tuber-
culosis? Can your staff spot symptoms of TB?
TB is a growing problem. There have been
three cases of known exposure in Iowa since
December. The Center for Disease Control
(CDC) released final guidelines on infection
control. Although TB is now covered under
the OSIIA general duty clause, there is a pro-
posal for TB standards in OSIIA.
Physician offices are advised to start think-
ing about a policy when this proposal
becomes law. The IMS Office Safety and
Compliance seminar (see box below for
details) will cover this and many other safety
issues. An OSIIA industrial hygienist will pre-
sent OSIIA regulations at this seminar,
scheduled for several sites around Iowa.
Retirement readiness
The Iowa Medical Society will sponsor a
workshop on retirement readiness in three
locations in Iowa during May.
The workshops will be taught by Jerry
Foster, president of Retirement Advisors, Inc.
The seminar, designed for physicians and
their spouses, answers important questions
for physicians preparing for retirement:
•IIow much is enough?
•Can I retire at my target age?
•Can I outlive my resources?
•IIow can I control taxes?
•Will I be emotionally ready to retire?
The cost of the seminar is §125 for mem-
bers (§150 for a member couple); §175 for a
non-member (§200 for a non-member cou-
ple). All prices include lunch.
The retirement seminars are planned for
Wednesday, May 10 in Cedar Rapids;
Wednesday, May 17 in Davenport; and
Wednesday, May 24 in West Des Moines. For
more details on upcoming seminars, check
the insert in this month’s Iowa Medicine. E3
Upcoming IMS Services seminars for you
Specialty Coding Extravaganza
Tuesday, Wednesday, Thursday
April 18, 19 and 20
Best Western Des Moines
International
CPT ; ICD-9 & HCPCS coding for
specialties
* Office Safety/Compliance
Wednesday, May 10, Iowa City
Thursday, May 11, Lake City
Wednesday, May 17, Marshalltown
Thursday, May 18, Burlington
Wednesday, May 24, Dubuque
Wednesday, May 31, Council Bluffs
* Anatomy and Physiology
Tuesday, May 9, Cedar Rapids
*Thcse seminars are part of the
IMS Medical Business Specialist
(MBS) certificate program
For more information on any seminar, call Mary Reinsmoen or Sherry Johnson at the IMS, 515/223-1401 or
800/728-5398.
156 Iowa Medicine Volume 85/ 4 April 1995
—
CURRENT ISSUES
Midwest Medical Insurance Company Focus on Risk Management
Medication errors
Prescription of medication. It’s one of the
most common procedures performed in the
physician’s office. A recent study of malprac-
tice claims reveals that medication error
claims are one of the most common and
expensive areas of malpractice losses.
The study by the Physician Insurers
Association of America emphasizes that med-
ication errors can cause significant patient
injuries and that many of these injuries and
medication-related malpractice claims can be
avoided by using these risk management steps:
•Chart all prescriptions and refills on a
medication flowsheet.
•Obtain and document medication histories
and update them as necessary.
•Inquire about and document allergies in a
New Start Date for Management Education Program
Sponsored by the Iowa Medical Society & Iowa Medical Group Management Association
consistent and conspicuous location.
•Read the medical record for contraindic-
tions to medications, excessive number of
refills and allergies.
•Educate patients about their medications.
•Obtain and document informed consent
for prescription medications with potentially
significant drug complications and side effects.
•Monitor drug usage, particularly with con-
trolled substances.
For further information, contact Lori Atkinson,
MMIC risk management coordinator, MMIC West
Des Moines office, PO Box 65790, West Des
Moines, 50265, 800/798-9870 or 515/223-1482.
The start date for the next MEP has been changed to May 19-20, 1995.
This allows more time for those people who need to adjust
their schedulesand obtain approval for tuition.
Registration deadline is April 24, 1995.
Response to the MEP has been good, including registrations from Des Moines, Waverlv, Kalona, Iowa City, Atlantic,
Boone, Dubuque and Fort Dodge. All classes are held at IMS headquarters in West Des Moines. This 12-month
program is held one weekend a monthfrom 1 : 00-6:00 p.m. on Friday and from 8:00 a.m.-l :00 p. m. Saturday.
If you’ve been avoiding the time and financial commitment of enrolling in an MBA program, please give
consideration to joining this MEP, a mini MBA program. Dr. James White, IMS president, says physicians’ roles are
changing. “Today, physicians have to be more than clinicians. Physicians must also be managers. ” Alice
Eveleth, president of IMGMA, says clinic administrators “must be knowledgeable in a wide variety of
i management leadership topics. Today, more than ever, survival depends upon physicians and administra-
i tors working as partners. ”
The MEP introduces physicians and administrators to the business and management knowledge they need to
succeed as leaders and managers in today’s health care environment. The program improves communication and
teamwork between administrators and physicians to facilitate better integration of administration and clinical
decision-making.
For more information, including a schedule, call Mary Reinsmoen at the
Iowa Medical Society, 800/728-5398 or 515/223-1401.
Iowa Medicine Volume 85 / 4 April 1995 157
Iowa [Medicine
Newsmakers
AT A GLANCE
Dr. John Eckstein has
been selected by the Sec-
retary of Veterans Affairs
as a VA Distinguished
Physician. Dr. Eckstein,
who served over 20 years
as Dean at the UI College
of Medicine, joins 11 other
physicians in this presti-
gious program. During
his three-year appoint-
ment, he will serve as
consultant to VA leaders
and advisory boards
across the nation.
•
Dr. Laverne Winter-
meyer, Iowa state epide-
miologist, has retired af-
ter 18 years with the Iowa
Department of Public
Health. The new state
epidemiologist is Dr. M.
Patricia Quinlisk, for-
merly of Oklahoma.
•
Dubuque’s Finley Hospi-
tal has been selected as
one of the 100 Top Hospi-
tals— Benchmarks for
Success Honorable Men-
tion Award Winners in a
research report from
Health Care Investment
Analysts, Inc., a Balti-
more-based research
company and Mercer
Management Consulting,
Inc., New York.
Awards, appointments, etc.
Dr. Michael Jones, UI College of Medicine
associate professor of preventive medicine and
environmental health, was appointed Interna-
tional Biometrics Society representative to the
American Association for the Advancement of
Science for the Eastern North American Re-
gion. Dr. Susan Johnson, UI associate profes-
sor of obstetrics and gynecology, has been
appointed by the National Board of Medical
Examiners as a member of the U.S. Medical
Licensing Examination (USMLE) Step 2 Test
Material Development Committee. The USMLE,
a joint program of the Federation of State
Medical Boards and the National Board of Medi-
cal Examiners, provides a common evaluation
system for all medical license applicants in the
U. S. Dr. Madeline Shea, UI assistant professor
of biochemistry, has been elected to a four-year
term on the council of the Biophysical Society.
Researchers at the UI have received a grant
from the Centers for Disease Control and Pre-
vention to investigate the health status of Io-
wans who served in the Persian Gulf War. Dr.
David Schwartz, associate professor of internal
medicine, heads up the research team. Dr.
Gary Koretzky, UI associate professor of physi-
ology and biophysics and internal medicine,
was appointed to the Kelting Chair in Internal
Medicine, which supports the work of a faculty
member involved in arthritis research. Dr.
Koretzky also received the 1994 Young Investi-
gator Award from the Midwest Region of the
American Federation for Clinical Research at
the Federation’s annual meeting in Chicago.
Dr. Douglas LaBreeque, UI professor of inter-
nal medicine, was appointed treasurer for the
World Congresses of Gastroenterology. Dr.
Robert Woolson, UI professor of preventive
medicine and environmental health, has been
elected to a three-year term on the board of
directors for the Society of Clinical Trials,
which has about 2500 members interested in
the development of scientific methods for the
design, analysis and operations of controlled
clinical trials. Dr. Michael Pfaller, UI professor
of pathology, has been appointed to the edito-
rial board of Clinical Infectious Diseases. Dr.
Richard Nelson, UI professor of pediatrics, has
been appointed executive associate dean. Dr.
Thomas Weingeist, UI professor and head of
ophthalmology, was re-elected to a three-year
term as senior secretary for Clinical Education
of the American Academy of Ophthalmology.
Dr. Randy Kardon, UI associate professor of
ophthalmology, has received a five-year career
development award from the Veterans Admin-
istration to support research in the neuro-
physiology of the pupil of the eye. He was one of
seven physicians in the nation to receive the
award. Dr. Edwin Stone, UI associate professor
of ophthalmology, received a $55,000 award
from the Grousebeck Foundation for studies on
Leber’s optic neuropathy, a hereditary disor-
der which often leads to blindness in young
men aged 10 to 21. Dr. Wallace Alward, UI
associate professor of ophthalmology, received
a $15,000 unrestricted research grant from the
Glaucoma Foundation to pursue studies deal-
ing with the diagnosis and treatment of glau-
coma. Dr. Peter Densen, UI professor of inter-
nal medicine, has been appointed associate
dean for student affairs and curriculum. Dr.
Densen has served in this position on an acting
basis since 1992. Dr. Edmund Franken, Jr., UI
professor of radiology, has been named the first
Roentgen Centennial Fellow in Radiologic In-
novation by the Radiology Society of North
America. Dr. Franken will receive up to$100,000
for teleradiology research.
New members
Newton
Lafayette Twyner, MD, family practice
Orange City
Steven Locker, MD, general surgery
Ottumwa
Herbert Maealalad, MD, internal medicine
158 Iowa Medicine Volume 85/4 April 1 995
Office Safety
and
I Compliance
Issues^
l
I
Anatomy
and
Physiology^
This half-day class reviews suggested and required safety programs for physician
offices. Workers’ Compensation, OSHA, ADA and general office safety are
included. Seminar time is 1:00 p.m. to 4:30 p.m. COST: #85 for IMS member
or staff: # 140 for non-member or staff. Representatives from the Iowa OSHA and
the Iowa Farm Bureau will join Mary Reinsmoen of the IMS staff in presenting this
program.
DATE
CITY
SITE
Wed 5/10
Iowa City
Mercy Hospital Medical Plaza, Scanlon Room
Thu 5/11
Lake City
Stewart Memorial Hospital, Conference Center
Wed 5/17
Marshalltown
Marshalltown Medical & Surgical Center, Room A
Thu 5/18
Burlington
Burlington Medical Center, Room 4
Wed 5/24
Dubuque
Finley Hospital, Auditorium
Wed 5/31
Council Bluffs
Jennie Edmundson Memorial Hospital, Auditorium
This full-
-day introductory
class provides a basic understanding of anatomical
structure and function. The major systems of the human body are covered in this
practical course and a text is included. Seminar time is 9:00 a.m. to 4:00 p.m.
COST: {5150 for IMS member or staff (includes lunch); #240 for non-member
or staff (includes lunch). Instructor: Craig A. Canby, Ph.D., Assistant Professor
of Anatomy at the University of Osteopathic Medicine and Health Sciences in Des
Moines, Iowa.
DATE
Tue 5/9
CITY SITE
Cedar Rapids St Luke’s Hospital Resource Center Formal Lounge
■
1
Retirement
l Readiness
J
1
■
This workshop-format class is designed especially for physicians and spouses to
attend as a couple. Topics include how much it will cost to retire, how to save for
retirement and how to invest retirement funds. A personal financial planning
conference can be arranged following the workshop. The presenter is Jerry Foster,
president of Retirement Advisors, Inc., West Des Moines. The seminar time is
10:00 a.m. to 3:30 p.m. in all locations. COST; #125 for IMS members (#150
for member couple); #175 for non-member (#200 for non-member couple). All
prices include lunch.
DATE CITY SITE
Wed 5/10 Cedar Rapids St. Luke’s Medical Office Plaza, Room 2
Wed 5/17 Davenport Genesis East, Interconnect Lounge
Wed 5/24 West Des Moines IMS Headquarters, Bierring Room
★ These programs are part of the IMS Medical Business Specialists (MBS) Certificate Program.
Registration Form
Office Safety Anatomy & Physiology Retirement Planning
Name(s):
Clinic/Practice Name:
Address:
Phone: Fax:
Amount Enclosed: Date and Location:
Please make checks payable to IMS Services. Mail check and registration form to:
IMS Services ATTN: Sherry Johnson, 1001 Grand Avenue, West Des Moines, LA 50265-3599.
Kent Walker, MD, dermatology
Pella
Lee Henry, DO, diagnostic radiology
Craig Wittenberg, MD, family practice
Perry
Jeffrey Allyn, MD, family practice
William Durbin, MD, family practice
Kurt Klise, MD, family practice
Steven Sohn, MD, family practice
Sheldon
William Jongewaard, MD, general surgery
Sioux City
David Erlbaeher, MD, resident
Allan Fischer, DO, internal medicine
Gary' Ilattan, MD, resident
Christopher Hughes, MD, neurology
Alan Kessler, DO, resident
James Lauck, Jr., MD, family practice
Jerome McFadden, DO, resident
Kelly Moser, MD, resident
Mary Ryken, MD, psychiatry
David Wagner, MD, otolaryngology
Tipton
Kamala Cotta, MD, internal medicine
Karyn Shanks, MD, internal medicine
Waterloo
Tom Baecain, DO, resident
John Holley, MD, resident
Thomas Mitchell, MD, resident
Steve Olsen, DO, resident
Malati Pamulapati, MD, resident
Robin Plattenberger-Gilmore, DO, resident
Waverly
Daniel Damold, MD, family practice
Webster City
Wayne Vending, II, DO, diagnostic radiology
West Des Moines
Lynn Nelson, MD, orthopaedic surgery
Sally Jo Studer, DO, family practice
Deceased member
Frank Richmond, MD, 101, life member, fam-
ily practice, Fort Madison, died October 1 IE]
One Call
One Source
HHM
HAWKEYE
MEDICAL
SUPPLY, INC
The Medical and Office Supply Leader in the Midwest since 19751
Why waste valuable staff time coordinating orders, shipments, and supplies with
multiple vendors when Hawkeye Medical Supply, Inc. does it alii
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Des Moines
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iiii
Iowa Medicine Volume 85 / 4 April 1995 159
Genesis
Regional
Heart Center
Friday, July 28, 1995
Jumer’s Castle Lodge
Bettendorf, Iowa
Faculty
§)
WILLIAM W. PARMLEY, M.D.
Professor of Medicine, USFC; Chief
of Cardiology, Moffitt/Long Hospital,
San Francisco, California.
til M
PAUL H. KRAMER, M.D.
Medical Director, Cardiovascular
Laboratories, Mid America Heart
Institute of St. Luke’s Hospital,
Kansas City, Missouri.
0%
1
ARTHUR MOSS, M.D.
Professor of Medicine, University
of Rochester Medical Center,
Rochester, New York.
FREDRICK (FRITZ) HAGERMAN, PhD.
Professor of Biological Sciences,
Ohio University, Athens, Ohio,
MARJORIE TROLLER HAGERMAN
MS, RD, LD, Chair, Foods & Nutrition
and Director, Didactic Program
in Dietetics, Ohio University, Athens, Ohio.
NANETTE KASS WENGER, M.D.
F.A.C.C., Professor of Medicine (Cardiology)
Emory University School
of Medicine, Atlanta, Georgia.
james McClelland, m.d.
Assistant Professor, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
Puttin’ on the Bex:
Music and
Medicine
Now in its fifth year, Cardiology
at the Bix, sponsored by Genesis
Regional Heart Center features
internationally acclaimed speakers,
as well as attendees from all over
the country. Held at the beautiful
Jumer’s Castle Lodge in Bettendorf,
it draws internationally acclaimed
physicians.
Attendees can also enjoy the
Bix Beiderbecke Memorial Jazz
Festival, which features top-notch
bands from around the world and
honors Davenport native son and
jazz great Bix Beiderbecke.
More than 20,000 runners are
expected for what Runner’s World
calls “the road race with the most
community spirit.” Scheduled for
July 29, the Bix 7 is the eighth
largest road race in the United States.
Registration Information:
Registration Fee: $95 Physician $55 Nurse/Allied Health Professional
Fee includes attendance at the symposium, a ticket to the ‘Friends of Bix’
Cocktail Party, and a complimentary dinner aboard the Casino Rock Island.
Registration deadline is July 3, 1995. Confirmation and
entertainment details will be sent upon registration.
For further information, please contact Anne Pauly (319) 383-1062.
GENESIS
MEDICAL CENTER
Genesis Regional Heart Center
1227 East Rusholme Street
Davenport, Iowa 52803
Iowa [Medicine
DEAN’S MESSAGE
UI College of Medicine
in the 21st century
The University of Iowa College of Medicine
is well on its way into the 2 1st century and
I’m proud to be able to serve in a leader-
ship role for this well-respected medical col-
lege.
The leadership challenges we face as part of
an academic health sciences center will be to
manage change together to provide the highest
quality health care at the lowest possible cost
with the greatest efficiency; provide outstand-
ing education and training to our students — the
future health care professionals of Iowa and the
world; and foster the best environment for
research that pushes forward the frontiers of
science.
As is the case with most academic health
sciences centers, the University of Iowa College
of Medicine faces challenges from
the market-driven changes in
health care delivery. We’re having
to reinvent our centers to have
access to future streams of clinical
income — which can account for
as much as 40% of a medical
college’s funds. Only then can we
continue to fulfill our education,
research and clinical service missions to the
people of Iowa.
Above all, we must meet society’s needs,
especially in providing more generalist physi-
cians. We must also meet Iowa’s needs for
health care and services to rural areas.
Renewal time for medical curriculum
As a strong supporter of educational innova-
tion, I was inspired when our faculty recently
gave the green light to the Medical Education
Committee to proceed with revamping the cur-
riculum. Through these changes in structure
and content and other unique features in what
we call the “generalist curriculum,” the educa-
tion we provide will be responsive to the envi-
ronment and advances in medical knowledge.
On another educational front, the College
continues to contribute to the quality of health
care by providing extensive continuing educa-
tion opportunities for physicians and other
health professionals. In 1994, the College spon-
sored more than 200 conferences and work-
shops and instituted a new competitive grant
program for faculty to develop community-
based education programs that utilize the Iowa
Communications Network (ICN). The College
sponsored its first continuing edu-
cation course via the ICN in March .
Managing change through inter-
disciplinary research
In the spirit of fostering inter-
disciplinary research that’s more
discipline-oriented, the UI Cancer
Center won an interdisciplinary
planning grant stimulating further
joining and collaboration of the varying cancer
research interests across campus.
We believe the University of Iowa can be-
come a national leader with a cancer center
focusing on the special needs of rural popula-
tions. We’re working to seek formal designation
of the center by the National Cancer Institute.
This and like initiatives are becoming more
important to ensure high quality research and
We must
meet Iowa’s
needs for
health care
and services to
rural areas.
Robert Kelch, MD
Dean, University of Iowa
College of Medicine
Dr. Kelch, a pediatric
endocrinologist, assumed
the deanship of the UI
College of Medicine in
August 1994 after more
than 20 years on the
faculty of the University
of Michigan.
Iowa Medicine Volume 85 / 4 April 1995 161
Iowa] Medicine
DEAN’S MESSAGE
While we’re not
overproducing
generalist
physicians, we
do have a
distribution
problem.
Dean’s Message
continued
cost effectiveness. Our Cancer Center and its
interdisciplinary push is one example of other
programmatic developments we’ll see in the
near future.
Financing educational programs
As crucial as these programs are, questions
always arise about how we’re going to finance
them and meet society’s needs. As we move our
clinical teaching to ambulatory settings, the
cost of medical education will increase strik-
ingly. We can’t and won’t ask our students to
bear the full burden of these increasing costs.
We believe it’s better to involve and seek assis-
tance from community providers. They can
assist in the teaching process, and perhaps
more indirectly, bring an awareness to society
as a whole that supporting education is worth-
while especially as we attempt to better meet
the primary health care needs of Iowans.
Producing health professionals
A serious look at the production of health
care professionals, including the cost of their
training and quantity produced, is probably
warranted.
While we’re probably not overproducing gen-
eralist physicians, we do have a distribution
problem. We believe the more our students and
faculty get out in the communities and partici-
pate in education and training sessions, we’ll
likely facilitate recruitment and retention of
physicians in those areas. Getting residents
into underserved areas for training is also im-
portant. Studies have shown that the regional
location of a physician’s graduate training pro-
gram is a key determinant of his or her practice
location.
I’m proud to join you and be part of the rich
tradition of collegiate involvement that we have
with the Iowa Medical Society. HD
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162 Iowa Medicine Volume 85/4 April 1995
Medical Protective Policyowners
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no strings attached! In an era of frivolous suits, changing government attitudes about the
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committees, shouldn't you have The Medical Protective Company as your professional liability
insurer? Call your local General Agent for more information about how you can have more control
in defense of your professional reputation.
Iowa Medicine
FEATURE ARTICLE
A new course for
Medical
Education
Peter Desses, MD
Dr. Den sen is associate
dean for student affairs
and curriculum at the
Un ive rs i ty of Iowa
College of Medicine.
When first-year medical students arrive at the University of
Iowa College of Medicine th is coming fall, they will begin
the educational journey to a medical career along a new
path — a revamped undergraduate medical curriculum.
Prompted by the exponential growth in
medical knowledge, the increasing signif-
icance of teaching in ambulatory care
settings and the impact of managed health
care on medical practice, the University of
Iowa College of Medicine initiated a detailed
study of its curriculum in the fall of 1991.
The findings of this review were distrib-
uted widely in 1993 and served as the start-
ing point for proposed modifications in the
structure, content, setting and pedagogical
processes of medical education at the UI.
On November 14, 1994, College of
Medicine faculty voted overwhelmingly in
support of proceeding with detailed
development and implementation of these
changes, the first phase to begin with the
class entering this fall.
Major changes in emphasis
Major changes in emphasis
include earlier patient exposure,
increased integration and clinical
relevance in the basic science
courses and community-based
primary care in the clinical years.
Structural revisions include
limiting contact hours to 24 hours a week in
the preclinical years and increasing the
weeks of required course work in the senior
year while retaining 20 weeks of elective
time.
Curriculum management is also being
restructured, with increased responsibility
allocated to six curriculum directors: one for
each of the first four semesters, one to
oversee the clinical years and another for a
new three-semester course entitled “The
Foundations of Clinical Practice”. These
directors will be charged with assuring
integration of material among courses in a
semester and between semesters, as well as
assuring clinical relevance of course content.
Earlier exposure to patients
As currently envisioned, the first year will
begin with semester-long courses
in gross anatomy and bio-
chemistry. A 10-week molecular
and cellular biology course will
give way to a course in medical
genetics that runs through the
remainder of the semester. The
spring semester consists of a core
Major changes in
emphasis include
community-based
primary care
in the clinical
years.
164 Iowa Medicine Volume 85 / 4 April 1995
FEATURE ARTICLE
course that seeks to integrate
functional anatomy, histology,
embryology and physiology from
an organ system approach.
A greatly revised course in
neuroscience will run parallel with this
integrated systems core. Running concur-
rently with the basic science courses, the new
course, “The Foundations of Clinical Practice”,
will give students their first exposure to
patients, disciplines such as preventive
medicine and critical appraisal skills.
Major goals for this course include
developing the interpersonal skills critical for
patient interactions and facilitating students’
transition to an adult style of learning.
Focus on skills of generalists
Another unique feature of the revised
curriculum is the greater emphasis to be
placed on the skills and body of knowledge
the generalist requires. This will coincide
with the minimum core of material that the
College envisions having all students master
prior to graduation.
One way the new curriculum seeks to do
this is through the generalist core of
clerkships, which includes community-based
primary care, family practice and internal
medicine ambulatory care, general internal
medicine, obstetrics and gynecology and
pediatrics.
When students begin their full-time
clinical experiences, they will be required to
complete two of the six six-week clerkships
comprising the generalist core before
fulfilling the broader array of curricular
mandates.
Six clerkships complete by third year
All six of the generalist core clerkships
must be completed by the end of the third
year. This way the basic skills just acquired
in the second-year introduction to clinical
medicine course will receive appropriate
early reinforcement.
A six-week community-based primary care
rotation will serve to further acquaint
students with the settings in which generalist
physicians practice medicine.
Successfully implementing this generalist
curricular component will depend on the
development of extramural educational
campuses and will require the cooperation
and collaboration of many physicians
throughout Iowa. The College of Medicine
welcomes the opportunity to collaborate with
all Iowa physicians in this important
endeavor. HO
A new course, “The
Foundations of
Clinical Practice”,
will give students
their first exposure
to patients.
Iowa Medicine Volume 85 / 4 April 1995 165
Iowa Medicine
FEATURE ARTICLE
Beyond measles and influenza:
The future of
Vera Dordick
Ms. Dordick is assistant
director of Health Science
Relations at the Univer-
sity of Iowa College of
Medicine.
vaccines
The usefulness of antibiotics has become more limited due to
the growing ability of bacteria to become resistant. The
preventive potential of vaccines may offer solutions to some
of today’s medical challenges, say UI experts.
Long before Edward Jenner’s landmark professor and head of microbiology. “In the
experiments opened the way for the
development of the smallpox vaccine, ancient
Chinese physicians practiced inoculation for
the disease. Today’s medical scientists,
future, physicians will be armed with a wider
array of vaccines that may be delivered in
very novel ways.
“Before the 1950s, only killed vaccines of
armed with the advanced tools of molecular whole organisms were available,” Apicella
says. “Now we are finding components of
bacteria that can be modified, or attenuated,
for use in vaccines.” For example, the ‘old’
pertussis vaccine had many side effects, some
quite serious. Scientists have modified the
vaccine, eliminating its toxic component.
The new and the improved
Some vaccines may be closer at hand than
others. Apicella predicts that the next major
victory will be improved vaccines for
They are looking for the mechanisms these pneumococcal pneumonia, a major cause of
culprits use to infect humans. Knowledge death among the elderly and in developing
about how these microbes operate countries.
could help investigators design ^ flitUTC, ^ vaccine for middle ear
ways to interfere with those physicians will be
mechanisms and ultimately armed with a wider
develop strategies for vaccines. array Of V3CCineS
delivered in very
novel ways.
biology and genetic analysis, are still
searching for ways to guard against the
microorganisms that ail us. What they’re
finding may offer new protection against
disease and improve the way vaccines are
delivered, adding to the variety of vaccines
that have become public health staples.
Researchers throughout the University of
Iowa College of Medicine are exploring
bacteria and viruses ranging from Pseu-
domonas and Gonococcus to papillomavirus.
“There are tremendous
opportunities for new vaccines,”
says Dr. Michael Apicella, UI
disease — a source of woe for
many young children — may also
be around the corner. Dr. Apicella
has patented one, based on a
protein in the cell wall of the
haemophilus bacteria, which is
166 Iowa Medicine Volume 85 / 4 April 1995
currently in the first phase of clinical trials.
“Pneumococcal bacteria can also cause
middle ear diseases, and the proteins in its cell
wall might also be useful,” says Dr. Apieella.
Efficacy of TB vaccine varies
For other diseases, like tuberculosis,
existing live vaccines provide limited
protection.
“The current tuberculosis vaccine has
varied widely in efficacy, doesn’t allow for TB
skin testing and is probably not as effective
for pulmonary TB, the most common type,”
says Dr. Larry Schlesinger, UI assistant
professor of internal medicine. “The
resurgence of TB during the past decade and
the rising number of antibiotic-resistant
strains of TB have heightened interest in
preventing the disease.”
Schlesinger’s laboratory team is trying to
identify the major molecules on the TB
bacterium that allow it to enter specialized
white blood cells called macrophages. These
cells serve as the normal host niche for the
bacterium.
“Our long range goal is to determine
whether vaccinating people with the
bacterial molecules will create immune
responses that block the bacterium from
entering macrophages. We want to find a way
to interrupt the life cycle of the organism,”
he explains.
“We’re also working to create molecules
for specifically identifying and destroying the
white cells that carry bacteria. This will serve
as a form of targeted immunotherapy that is
similar to cancer treatment approaches.
Hope for fighting viruses, parasites
Developing vaccine strategies for viruses
presents different challenges, however. The
human papillomavirus (HPV), the most
common viral sexually transmitted disease
today, lives in human cells and uses their
machinery to replicate and maintain its life
cycle, says Dr. Patricia Winokur, UI assistant
professor of internal medicine. Prevention
strategies are key, because therapies for
genital warts are inefficient and don’t prevent
recurrence, she adds.
“It’s difficult to interfere with HPV and
leave the surrounding tissues unharmed. We
know that two viral proteins interact with
each other and with the host cell. These two
proteins could provide important targets for
new antiviral therapies,” she explains. “A
vaccine for HPV is far in the future.”
Vaccines for parasitic diseases have
proven just as elusive. While not common in
the U.S., leishmaniasis, spread through the
bite of the sandfly, is a major problem in
many areas of the world. The fatal visceral
form of the disease is epidemic in Sudan,
Brazil and India.
“Current treatments for Leishmania have
toxic side effects. A vaccine would be
extremely useful, particularly for developing
countries where access to medical care is
limited,” says Dr. Mary Wilson, UI associate
professor of internal medicine.
Wilson is examining parasite proteins that
might be useful in developing a vaccine,
particularly if they are given with another
organism that might enhance the immune
continued
Therapies for
genital warts are
inefficient and
don’t prevent
recurrence.
Iowa Medicine Volume 85 / 4 April 1995 167
Iowa | Medicine
F E ft T U R E A R T I C L E
continued
Tomorrow’s patient
will likely receive
these new vaccines
through novel
delivery methods.
response. She also studies other aspects of
leishmaniasis, including the possibility of a
genetic tendency toward the development of
visceral leighmaniasis.
Wilson and John Donelson, UI professor of
biochemistry and Howard Hughes Medical
Institute investigator, are examining a
surface protein on the parasite that appears
to be associated with its virulence.
She and Dr. Bradley Britigan, UI professor
of internal medicine, are also studying how
the parasite enters a macrophage and how it
is able to survive the toxic materials that the
macrophage produces to kill it.
Innovative ways to immunize
Tomorrow's patients will likely receive
these new vaccines — as well as today’s
proven vaccines — through novel delivery
methods.
“Using adjuvants, such as microscopic
beads with pores, vaccines could be delivered
through timed release over the long term.
For example, a newborn infant in the nursery
would receive a multicomponent vaccine
that releases its ingredients at specified
times, thus eliminating the need for repeat
inoculations,” Dr. Apicella explains.
Vaccines based on attenuated bacteria will
also give way to oral vaccines.
“Once ingested, the vaccine enters the
lymphatic sites in the gastrointestinal tract
and creates immunity,” Dr. Apicella says.
The preventive potential of new vaccines
may offer solutions to some of today’s
medical challenges.
“It’s clear that antibiotics have limited
usefulness due to the growing ability of
bacteria to become resistant,” Dr. Apicella
concludes.
Therefore, regardless of how they are
delivered, vaccines will play an ever
increasing role in the “big picture” of public
health. E2
168 Iowa Medicine Volume 85 / 4 April 1995
Do YOU NEED TO RECRUIT
A NEW PHYSICIAN
OR
DO YOU HAVE MEDICAL EQUIPMENT
TO SELL?
Try advertising in Iowa Medicine \s
Classified Advertising Section
Iowa Medicine offers display classified advertising at a resonable cost
Display classified advertising rates are $25 per column inch. A variety of type sizes, borders, reverses
or screens can be included in your ad. Ad sizes range from 1 column by 2" deep to 1 column by 6"
deep. Please specify the size and the design (screens, reverses, borders) or use example A, B or C.
If not specified, the editors will use their best judgement.
A Great Opportunity
We are seeking a general inter-
nist or family practitioner with
geriatric interest. An entrepre-
neurial spirit is essential.
The professional chosen for this
position will launch an evolving
group practice in Any town, Iowa.
A very attractive benefit package
(including practice equity) en-
hances this offer.
Please contact Placement Dept,
for detailed information.
123/456-7890
Example A
Surgeon, Mt. Ayr
• Paid Malpractice
• Competitive Compensation
• Flexible Schedule
• Incentives
• Full or Part-time
For more information
contact Dr. Jones at 123/456-7890
Example B
For more
information or
to place a
display classified
ad. call Jane or
Bev at 515/223-
1401 or 800/
747-3070, fax
515/223-8420.
Family Practice
Medical group is searching for a family
practitioner to help direct Family and
Urgent Care practice in Any Town,
Iowa. Send CV to:
Medical Group
1234 Your Street
Any Town, Iowa 12345
Attn: Medical Director
Deadline for
advertising is
the first of the
month preceding
publication.
Example C
STATEWIDE
PHYSICIANS
HEALTH
Over 10,000 individuals are protected by the Iowa
Medical Society-sponsored STATEWIDE PHYSICIANS
HEALTH INSURANCE PROGRAM. It’s stable cover-
age with competitive rates.
If you’re not one of the SPHIP insureds, you may want
to explore the program’s many coverage options —
both medical and dental. We’ll be glad to supply
information specific to you and your practice.
Endorsed and overseen by the IMS for its members,
their families and employees, the SPHIP has been
underwritten by Blue Cross Blue Shield of Iowa
since the program began 40 years ago. Today’s
program incorporates various deductibles and cover-
age formats.
Please call Ruth Clare, Terri DeGroot or Mary Sievers
for information about the program.
BERNIE LBWE 5c A5SBEIATE5. INE.
Insurance Administrators to Professional Associations &
Universities and Colleges
515-2EB-BB11 1-BBB-94B-471B FAX 515-BBB-B315
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West Bes Moines, Iowa 5BBB6-1411
Iowa | Medicine
SCIENCE AND EDUCATION
The Journal
of the I o w a Medical Society
Sports medicine education in the U.S.
# Damel Fick , MD; David Tearse, MD
Sports Medicine is a broad area of health care
which includes: 1 ) exercise as an essential
component of health throughout life; 2) med-
ical management and supervision of recre-
ational and competitive athletes and all
others who exercise and 3) exercise for pre-
vention and treatment of disease and injury.
The practice of sports medicine is the applica-
tion of the physician’s knowledge, skills and
attitudes to all persons engaged in sports and
exercise.
In 1987, Marion Alberts, MD, Iowa Medi-
cine scientific editor, voiced concern over the
care of high school athletes.' He specifically
listed inadequate examination of athletes,
poor facilities and exploitative coaches and
parents. lie felt there was a need to educate
and train those who care for athletic pro-
grams. At the time of Dr. Alberts’ original edi-
torial, there was little if any organized sports
medicine education in medical schools. As
recently as 1988, Whitley and Nyberg docu-
mented only five of 105 medical schools
offered a sports medicine course to medical
students.2
Seven years later, it seems as if sports medi-
cine has literally exploded in popularity and
profit. Unfortunately, this has created a situa-
tion where sports medicine advice and ser-
vices do not come from the medical profes-
sion. Whitley and Nyberg noted that
information and treatment programs often
comes from the news media, health establish-
ments and self proclaimed experts. These
“experts” often have little education, training,
or experience in sports medicine. Their moti-
vation is commercial and not based in scientif-
ic fact.
Physicians are the best source of informa-
tion and sendees in sports medicine today. As
experts in this field, we must take a leadership
position. However, if we are to do this, there
has to be undergraduate education in sports
medicine. We have to educate tomorrow’s
sport physicians while they are medical stu-
dents. Early exposure and education to med-
ical students in the field of sports medicine
will eventually produce doctors with training
and expertise which will allow them to provide
sports medicine care in a professional and
appropriate manner.
How has sports medicine’s current populari-
ty affected sports medicine curriculum in U.S.
medical schools? How many U.S. medical
schools have sports medicine courses and
which departments are offering the courses?
To answer these questions, we collected
information from all 126 U.S. medical schools.
Sports medicine electives were offered in 61
(48.4%) medical schools; 41 (57%) of these
were public schools and 20 (37%) were private
schools. There were 71 different listings at
these 61 medical schools. Eight medical
schools listed more than one separate elective;
six listed two courses and two listed three sep-
arate courses. Most courses were offered by
the departments of orthopaedics (66%). Prima-
ry care departments offered 28.1%. The course
descriptions provided by the catalogues varied
significantly (see Table 1 next page).
We found that U.S. medical schools have
responded to the sports medicine demand
with a 14-fold increase in courses over the last
five years. What started out as five courses in
1988 has grown to over 70 courses in 1993.
Three out of 10 courses are primary care
(family practice and pediatrics) in focus.
While orthopaedics has traditionally been
the leader in sports medicine, primary care
physicians are becoming more involved and
contributing increasing numbers to the ranks
of sport physicians. Several recent develop-
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
April 1995.
Damel Fick, MD
Dr. Fick is with the
Departments of Family
Practice and Orthopaedic
Surgery, University of
Iowa College of Medicine.
David Tearse, MD
Dr. Tearse is with the
Department of
Orthopaedic Surgery,
University of Iowa
College of Medicine.
Iowa Medicine Volume 85 / 4 April 1995 171
Iowa [Medicine
SCIENCE AND E D U C ft T I 0 N
Sports medicine education in the U.S.
continued
ments in primary care sports medicine has
helped move the specialty forward in the last
five years. Membership in the American Med-
ical Society for Sports Medicine (AMSSM), the
sister organization to the American Orthope-
dic Society for Sports Medicine (AOSSM), is
increasing. The boards of family practice,
internal medicine, pediatrics and emergency
medicine offered the first Sports Medicine Cer-
tificate of Added Qualification in the fall of
1993. Primary care sports medicine fellow-
ships have been increasing in number and
ACGME guidelines for primary care sports
medicine fellowship accreditations will be pub-
lished soon.
TABLE 1
CONTENT OF SPORTS MEDICINE ELECTIVES
Activity
# of courses
that listed activity
Fieldside participation
29
Operative assistance
28
Training room visits
21
Required reading
17
Conferences
13
Research or literature review
17
Organized lectures
10
Formal student evaluation
19
The comparison of orthopaedics and prima-
ry care raises an important issue — coopera-
tion of primary care and orthopaedics. The
authors of this article represent both primary
care and orthopaedic surgery. Recently, prima-
ry care has become part of the sports medi-
cine service that cares for over 200 Division I
athletes, in addition to thousands of high
school and recreational patients each year.
This cooperation has been mutually beneficial
for both specialties. With competition from
non-medical sources it is imperative physi-
cians work together to provide sports medi-
cine care to student athletes.
The University of Iowa offers medical stu-
dents the option of sports medicine electives
in both orthopaedic surgery and family prac-
tice. Sports Medicine education must begin in
our medical schools if we want to provide Iowa
student athletes with well trained and knowl-
edgeable physicians. EH
References
1. Alberts, ME: Sports medicine: Iowa Medicine
1987:77:453.
2. Whitley, JD and Nyberg, KL: Exercise medicine in
medical education in the United States. Phys Sportsmed
1988;16( 10):93-101.
r,
172 Iowa Medicine Volume 85 / 4 April 1995
Iowa [Medicine
n t t u i
u n
o u m m t n
As life passes by
Life can only be understood backwards,
but it must be lived forward.
Soren Kierkegaard, Danish scholar, (1813-1855)
Life is not dated merely by years. Events
are sometimes the best calendars.
Benjamin Disraeli (1804-1881)
These quotations exemplify the experi-
ences in our home during the past few
days. We have been sorting hundreds of
slides and prints taken of family members and
vacation places over the years. It is a tedious
task; yet an enjoyable one. A half century of
marriage has provided numerous memories
now brought to mind by viewing the pictorial
records of the past.
Recollection of events in the childhood years
of our four children has provided a
kaleidoscopic trip through the past.
The joys of parenthood interwoven
with the adventures of childhood
have been renewed. There is the
photograph of our youngest while
in an incubator that provided him
warmth and security during the
first weeks of his life. Another
photograph recalls the home-runs
by our oldest son while a Little Leaguer. An-
other reminds us of our youngest daughter
during her bout with chicken pox. And, an-
other of our oldest daughter in a beautiful blue
gown ready for her senior prom.
I am sure many of my older readers have
experienced the recollection of memories de-
picted by collections of slides and prints . . .
collections stashed away in projector trays,
photo albums, boxes and sometimes in the
same envelope in which the photographs were
delivered from the processors. Of course there
are some of you who have catalogued and filed
your photographic collections ready to be shown
at any time. But, when? Most of us shoot the
pictures, have the film developed, review the
photos and put them into a drawer, seldom to
be viewed again.
Our lives are much like these collections of
photographs. Memories imprint a view of past
events in our minds when we allow it. As
Kierkegaard said “Life can only be understood
backwards”. We can look back to the joyous
events of the past (yes, the unhappy events as
well) and relive life as we knew it. Yes, again as
Kierkegaard goes on to say, “but it [life] must be
lived forward”. I believe, we can
make our entire existence more
joyful and fulfilling. So many per-
sons harbor depressive attitudes
about their past that their present
dictates misery in the future. The
difficult events of the past often
caused concern, but were less dire
than anticipated at the time.
Life goes on. Cicero, the Latin philosopher,
said, “The life given us by nature is short, but
the memory of a well-spent life is eternal.”
Enjoy life. Look upon the past as experience
with good and bad memories. Look forward to
the future with anticipation, planning for a
continuation of events and joys that in a split
second will become part of the past. Qii]
We can
make our
entire
existence
more joyful
and fulfilling.
#
Marion .Alberts, MD
Iowa Medicine Volume 85 / 4 April 1995 173
BUDMULCAHYS
GRAND CHEROKEE LAREDO;
GRAND CHEROKEE LTD
IOWA'S LARGEST SELECTION
CHEROKEE COUNTRY
CHEROKEE SPORT
'95 SUMMIT ES
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STOP IN TODAY TO SEE OUR FULL LINE!
Iowa [Medicine
PHYSICIAN LEARNER
Retraining physicians
for primary care
There is much concern about physician
workforce imbalance. While some states
and regions find it difficult to recruit
primary care physicians and certain medical
specialists, other information suggests we face
an increasing surplus of physicians. Within
recent years a number of studies and commis-
sions have recommended that the nation aspire
to training as many generalists as medical and
surgical specialists. If such a proportion is to be
achieved, approximately 70% of graduating phy-
sicians from this time forward would need to
enter a true primary care discipline to attain
the 50/50 goal by the year 2020.
In the interim, physician unemployment (or
at least underemployment) may become part of
the American medical marketplace. In the
United States this phenomenon has probably
been less noticeable since physi-
cians have been willing to relocate
from high-density medical areas to
other regions of the country. In a
growing number of cases, physi-
cians who choose to remain may
accept static or reduced compen-
sation as a price for practice stabil-
ity. There is anecdotal evidence
that newly-minted subspecialists may be expe-
riencing difficulty obtaining any suitable posi-
tion regardless of their flexibility.
These observations have led to serious dis-
cussions about physician retraining. While some
proposals have centered on the retraining of
medical or surgical specialists to provide gener-
alist care, most of the interest is focused on the
retraining of subspecialists to provide more
primary care-oriented services. A recent ar-
ticle by Wall and Saultz in Academic Medicine
(April, 1994) described four pathways for re-
training available to the practicing physician.
The first is formal residency training in the new
discipline leading to board certification. A
second involves an organization, presumably a
certifying medical or surgical specialty, grant-
ing some type of certification of qualification for
an individual obtaining post-residency train-
ing. In a third pathway, a specific institution
might certify the individual to provide medical
care at that institution. Finally, an informal
apprenticeship pathway is described.
Within continuing medical education circles
there is a current effort to develop model cur-
ricula for at least the third and fourth pathways.
Any such programs would need to
be constructed carefully to meet
concerns of licensing boards and
hospitals or clinics in which physi-
cians might practice their “new”
discipline. It is possible that dem-
onstration education programs
may be developed in these areas,
although the lack of comprehen-
sive national health care reform suggests that
further marketplace evolution may be needed.
Physician retraining is an idea whose time
may not yet have come, but nevertheless an
idea that will be with us until the physician
workforce maldistribution improves. EE3
Newly-minted
subspecialists
may be experi-
encing difficulty
obtaining any
suitable position.
Iowa Medicine Volume 85 / 4 April 1995 175
Iowa|Medicine
Classified Advertising
Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: acute/urgent
care, family practice, oncology/hematology,
orthopedic surgery and general internal
medicine practice. The Mankato Clinic is a
70-doctor multispecialty group practice in
south central Minnesota with a trade area
population of +250,000. Guaranteed salary
first year, incentive thereafter with full range
of benefits and liberal time off. For more
information, call Roger Greenwald, Executive
Vice President, at 507/389-8500 or Byron C.
McGregor, Medical Director, at 507/389-8548
or write 1230 East Main Street, P.O. Box 8674,
Mankato, Minnesota 56002-8674.
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Marshalltown , Iowa
Best of both worlds — rural small group at-
mosphere, urban large group amenities. Seek-
ing quality emergency physicians interested
in stellar emergency medicine practice. Full-
time and regular part-time. 12Kvolume/12-
hour shifts. Democratic group, highly com-
petitive compensation, paid St. Paul mal-
practice with unlimited tail, excellent benefit
package/bonuses for full-time. Numerous
other Iowa locales. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021; 800/729-
7813 or 515/964-2772.
Staff Psychiatrist — Adult acute care IP/
residential and OP psychiatry in a public
general hospital with “continuum of care”
service. . .off-site clinic, crisis residential and
Medicaid managed care programs under
development. . .family practice residency,
student teaching. . .competitive salary,
incentive, 1 month vacation, CME allowance;
malpractice, disability, life, health, dental
insurance; state pension, voluntary pre-salary
annuity; shared call with 8 doctors. . .300,000
metro area, stable economy, moderate cost of
living, good schools, central location. . ..Tames
J. Pullen, MD, Broadlawns Medical Center,
1801 Hickman Road, Des Moines, Iowa 50314,
515/282-5700, fax 515/282-5732.
Emergency Medicine
Locum Tenens
Seeking quality physicians interested in
emergency medicine practice or primary
care locum tenens. Full-time and regu-
lar part-time. Numerous Iowa locales.
Democratic group, highly competitive
compensation, paid St. Paul malprac-
tice with unlimited tail, excellent ben-
efit package/bonuses to full-time phy-
sicians. Contact ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021.
Phone 1 -800 / 729-78 1 3 or 5 1 5 / 964-2772 .
Emergency Medicine, Dcs Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Gall me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Minneapolis, MN — Opportunities available for
BE/BC family practitioners with OB to join 6
person group. Western Minneapolis suburb.
No practice buy-in required. Excellent salary
and benefits. Please send CV or call Nancy
Borgstrom, Aspen Medical Group, 1021
Bandana Boulevard East #200, St. Paul,
Minnesota 55108, 612/642-2779 or fax 612/
642-9441. EOE.
Madison, Wisconsin — Dean Medical Center, a
300-physician multispecialty group, is seeking
additional family physicians to join its 30-
member department. Positions are located at
our Arcand Park, East Madison and Deerfield
Clinic locations. All positions have an
excellent call schedule and obstetrics is
optional. Madison is the home of the
University of Wisconsin with enrollment of
over 40,000 students and the state capital.
Abundant cultural and recreational opportuni-
ties are available year round. Excellent
compensation and benefits are provided with
employment leading to shareholder status.
For more information contact Scott M.
Lindblom, Dean Business Office, 1808 West
Beltline Highway, PO Box 9328, Madison,
Wisconsin 53715-0328, work at 1/800-279-
9966, 608/259-5151 or at home 608/833-7985.
An Equal Oportunity Employer.
Janesville, Wisconsin — Dean Medical Center,
a 300-physician multispecialty group, is
actively recruiting additional BE/BC internal
medicine physicians to practice at the
Riverview Clinic locations in Janesville, Milton
and Delavan, Wisconsin. Traditional internal
medicine and urgent care practice opportuni-
ties are available. Janesville, population
55,000, is a beautiful, family-oriented
community with excellent schools and
abundant recreational activities. Excellent
compensation and benefits are provided with
employment leading to shareholder status.
Send CV to Stan Gruhn, MD, Riverview Clinic,
PO Box 551, Janesville, Wisconsin 53547 or
call 608/755-3500. An Equal Opportunity
Employer.
Beaver Dam, Wisconsin — Medical Associates
of Beaver Dam is actively recruiting a BE/BC
family physician to join its staff of 6 family
physicians. Call is shared equally and all
hospital admissions are at our local 100-bed
hospital. Beaver Dam is a safe, family-oriented
community of 15,000 located 45 minutes
north of Madison with excellent schools and 4
season recreational opportunities. Excellent
compensation and benefits are provided. For
more information please contact Scott M.
Lindblom, Medical Staff Recruiter, Dean
Medical Center, 1808 West Beltline Highway,
1/800-279-9966, 608/259-5151, fax 608/259-
5294 or at home 608/833-7985.
176 Iowa Medicine Volume 85/ 4 April 1995
LeMarsy Iowa
Seeking quality physicians to prac-
tice at a 4300 average volume ER.
Director and staff positions. Full
and regular part-time. Democratic
group, highly competitive compen-
sation, paid St. Paul malpractice with
unlimited tail, excellent benefit pack-
age/bonuses to full-time physicians.
ACUTE CARE, INC., P.O. Box 515,
Ankeny, Iowa 50021; phone 800/
729-7813.
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
jan established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
lof Des Moines. We have a beautiful new
'facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salarv/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
'752-5469.
Time For a Move?— BC/BE FP, IM, OB/GYN,
PEDS. Our promise — We’ll save you valuable
time by calling every hospital, group and ad in
your desired market. You’ll know every job
within 20 days. We track every community in
the country, including over 2000 rural
locations. Cedar Rapids, Des Moines, Quad
Cities, Kansas City, Boston, Chicago, India-
napolis, many more. New openings daily — call
now for details! The Curare Group, Inc., M-F
9am-8pm, Sat 1-5 pm EST. 800/880-2028, Fax
812/331-0659.
Emergency Medicine, Council Bluffs, Iowa —
Opening available for qualified physician to
join group of emergency physicians. Training
and/or certification in primary care specialty
or emergency medicine. Flexible scheduling.
Newly remodeled emergency department.
Enjoy rural and urban atmosphere. Compen-
sation up to +8200K/vear plus vacation. Write
Bluffs Emergency Care Services, PC, 933 East
Pierce Street, Council Bluffs, Iowa 51503; 712/
328-6111.
Internal Medicine, Carroll, Iowa — Outstand-
ing professional opportunity for an internal
medicine physician in a progressive, safe and
clean community of 10,000. This opportunity
is available for either practicing internal
medicine physician, or the internal medicine
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more informtion, call Randy Simmons, vice
president, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
Sioux City — An excellent position is available
for a BC/BE family practice physician in a new
community health center. A full range of
family practice medicine is needed in a
community that is very supportive of the
center. Sioux City is a great place to raise a
family and has excellent public and parochial
school systems, a community college, 2 liberal
arts colleges, a graduate center, 2 excellent
medical centers, a Residency Training
Program (family practice), etc. The center
offers a competitive compensation and benefit
package, paid malpractice, etc. FEDERAL
LOAN REPAYMENT PROGRAM AVAILABLE.
For more information write Jeff Hackett,
Executive Director, Siouxland Community
Health Center, PO Box 2118, Sioux City,
Iowa 51104-0118 or call 712/252-2477.
No Assembly Lines Here — FPs, IMs and OB/
GYNs at North Memorial-owned and affiliated
clinics don’t hand patients off to the next
available specialist. Guide your patients
through their entire care process at one of our
25 practices in urban or semi-rural Minneapo-
lis locations. Plus, become eligible for 815,000
on start date. Interested BC/BE MDs, call 1/
800-275-4790 or fax CV to 612/520-1564.
Lancaster, Wisconsin — Dean Medical Center,
a 300+ physician private multispecialty group,
is actively recruiting for one board eligible/
board certified family physician to practice at
the Grant Community Clinic in Lancaster,
Wisconsin (population 4,200), an affiliated
clinic of Dean Medical Center. Their current
staff consists of 3 family physicians and one
general surgeon. The group also has 2
physician assistants on staff. Each physician
is at the clinic 6 hours a day, 4 days per week,
seeing between 20-25 patients daily. A
minimum 8110,000 guaranteed salary plus
incentive is provided. For more information
please contact Scott M. Lindblom, Medical
Staff Recruiter, Dean Medical Center, 1808
West Beltline Highway, 1/800-279-9966, 608/
259-5151, fax 608/259-5294 or at home 608/
833-7985.
Janesville, Wisconsin — Dean Medical Center,
a 300-physician multispecialty group, is
actively recruiting additional BE/BC family
physicians to practice at the Riverview Clinic
locations in Janesville, Milton and Delavan,
Wisconsin. Traditional family practice and
urgent care opportunities are available.
Janesville, population 55,000, is a beautiful,
family-oriented community with excellent
schools and abundant recreational activities.
Excellent compensation and benefits are
provided with employment leading to
shareholder status. Send CV to Stan Gruhn,
MD, Riverview Clinic, PO Box 551, Janesville,
Wisconsin 53547 or call 608/755-3500. An
Equal Opportunity Employer.
Madison, Wisconsin, Urgent Care — Dean
Medical Center a 300+ physician
multispecialty group is seeking full time
physician to assist in staffing our two urgent
care centers. Qualified applicants should be
BE/BC in family practice, emergency medicine
or internal medicine with experience in
pediatrics. Dean Medical Center operates two
Urgent Care Centers 365 days per year, from
7:00 a. m. -10:00 p.m. All physicians employed
at the urgent care centers are paid on an
hourly basis and full time physicians are
eligible to go on a shareholder track and buy
into the corporation after two years of
employment. Excellent compensation and
benefits with shareholder eligibility after two
years of employment. For more information
contact Scott M. Lindblom, Dean Medical
Center, 1808 W. Beltline Highway, PO Box
9328, Madison, Wisconsin 53715-0328, at
work 1/800-279-9966 or 608/259-5151 or
home 608/833-7985.
Lighted Slide Storage System — Stores 1000+
slides on illuminated racks. Find any slide
quickly and easily. Free catalog 800/950-7775.
Advertising Rates and Data
Regular classified advertising sells for S2.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for S25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85/ 4 April 1995 177
Iowa [Medicine
CLASSIFIED ADVERTISING
Janesville, Wisconsin, Urgent Care —
Riverview Clinic, a division of Dean Medical
Center, is actively recruiting an urgent care
physician to join its medical staff. We recently
increased our compensation package which is
based on a 40-hour work week. Total
compensation for Year 1 $108,000, Year 2
$134,642 and Year 3 $135,000. We currently
have two physicians which staff the clinic from
9:00 a.m.-9:00 p.m. Monday through Friday
and 9:00-11:30 a m. on Saturday and desire to
expand the hours of operation until 9:00 p.m.
on Saturday and 1:00-9:00 p.m. on Sunday.
Our facility is brand new and well equipped
with 8 exam rooms, lab and x-ray. Flexible
hours are available with an expected total of
30-40 hours per week. Excellent compensa-
tion and benefits are provided. For more
information contact Scott M. Lindblom, Dean
Medical Center, 1808 West Beltline Highway,
Madison, Wisconsin 53713, work phone 1/800-
279-9966 or 608/259-5151, fax 608/259-5294,
home 608/833-7985.
Family Practice, Carroll, Iowa — Outstanding
professional opportunity for family practice
physicians in a progressive, safe and clean
community of 10,000. These opportunities
are available for either experienced family
practice physicians, or the family practice
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more information, call Randy Simmons, Vice
President, at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
Family Practice Opportunity
Perry Memorial Hospital
Princeton, Illinois
BC/BE family practitioner needed immed-
iately for full practice in this friendly
community. Practice includes:
• Competitive salary and benefit package
• Call schedule of 1:4
• 35,688 person draw area
• Affiliation with 98-bed, JCAHO accred-
ited Perry Memorial Hospital.
Princeton, Illinois offers high quality
schools and a safe environment in which to
live and work, as well as various cultural
and recreational activities. Contact:
Marie Noeth at 800/438-3745
or fax your CV to 309/685-2574.
Ramsey Clinic — A 250-phvsician multi-
specialty group based in downtown St. Paul
operates a small network of clinics in
Maplewood and western Wisconsin. We
currently have 2 openings for board certified/
board eligible family physicians at Ramsey
Clinic-Maplewood and the Family Medical
Clinic in Antery, Wisconsin. Both clinics boast
personable physician colleagues and support
staff, bustling practices, private-like practice
settings and access to specialty consultations
and administrative support. Excellent call
schedule, a first year salary guarantee and
comprehensive benefits package. Send CV to
Aynsley Smith, Ramsey Clinic, 640 Jackson
Street, St. Paul, Minnesota 55101 or call 612/
221-4230.
LA CROSSE
WISCONSIN
• Live in beautiful Mississippi River Valley.
• Work with high quality colleagues in
growing multispecialty group (70 physicians).
• Competitive income/benefits.
SPECIALISTS NEEDED
Cardiology (Non-Invasive)
Critical Care/Pulmonary Medicine
Dermatology
Emergency Medicine
Family Practice
Internal Medicine
Neurology
Occupational Medicine
Orthopedic Surgery
Pediatrics
Urology
Send CV to: P. Stephen Shultz, M.D.
SKEMP CLINIC
800 West Avenue South
La Crosse, Wisconsin 54601
Fax 608/791-9898 or
Phone 608/791-9844, ext. 6329
178 Iowa Medicine Volume 85/ 4 April 1995
CLARKSON HOSPITAL
MEDICAL LECTURE
SERIES
May 5, 1995
8:00 a.m. - 5:00 p.m.
Practical
Rheumatology
Clarkson Hospital
Storz Pavillion
For more information
call
402/552-3039
■^r
PRIMARY CARE
PHYSICIANS
Heartland Primary Care is seeking BE/BC Primary Care physicians who
desire to join a progressive, hospital-employed group practice. You'll be
involved in all aspects of family medicine except obstetrics, providing clinical
coverage at a new hospital-based ambulatory care center and satellite offices
in St Joseph and nearby communities. To allow flexibility for your personal
life, you'll share call with other members of the Heartland Health System
Department of Primary Care.
Heartland Health System is a 600-bed bi-campus regional referral center,
serving 29 counties in Northwest Missouri and adjacent areas of Kansas, Iowa
and Nebraska.
• Guaranteed salary of $135,000 per year
• Medical student loan repayment options
• Malpractice insurance
• Health and life insurance
• Vacation
• Relocation expenses are provided.
For more information all Rhonda, 800-455-2480 or Heidi, 800455-2485.
Send CV to Heartland Health System, Medical Staff Development, 5325
Faraon, St. Joseph, MO 64506 or Fax to 816-271-6146.
Heartland
Health System
EOE
©1995 NAS
USAF HEALTH PROFESSIONS
TOLL FREE
1 -800-423-USAF
SPECIALIZE IN
AIR FORCE MEDICINE.
Become the dedicated physician you
want to be while serving your country in
today’s Air Force. Discover the tremen-
dous benefits of Air Force medicine. Talk
to an Air Force medical program manag-
er about the quality lifestyle , quality
benefits and 30 days of vacation with pay
per year that are part of a medical career
with the Air Force. Find out how to quali-
fy. Call
Iowa|Medicine
Professional Listing
Allergy
Emergency Medicine
John A. Caffrev, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljko K. Zivkovich, Ml)
Robert A. Colman, Ml>
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma , Allergy & Immunology
Dermatology
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
S trifling & Emergency’ Department Services
Family Practice
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Robert J. Barry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease ,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Bligard, MD, FAAD
James I). Bunker, MI), FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Bragc, Ml)
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gervich, MD
Daniel J. Schrocdcr, MD
Ravi K. Vemuri, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/I nfertility
IVF and GIFT Procedures
Donor Oocyte Program
A rtificial Insem i natio ns
Reproductive Surgery
Menopause Management
Internal Medicine
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MI), ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MI)
Laurence S. Krain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology , EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgese, MI)
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Ilosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
180 Iowa Medicine Volume 85/ 4 April 1995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert llavne, MD
Thomas A. Carlstrom, MD
David .1. Boarini, MD
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MD
S. Randy Winston, MD
Douglas R. Koontz, MI)
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad D. Abernathcy, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell H. Watt, MD
I John M. Gracthcr, MD
Gilbert W. Harris, MD
James A. Davison, MD
Norman F. Woodlief, Ml)
Eric W. Bligard, MD
David I). Saggau, Ml)
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert D. Whinerv, MD
Stephen II. Wolken, MI)
Robert B. Goffstein, Ml)
Lyse S. Strnad, MI)
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MI)
Michael L. Long, MD
Bradley L. Isaak, MI)
Randall S. Brenton, MD
James L. Dummett, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MI)
United Federal Building
700 4th Street, Suite 305
Sioux City 51 101
712/252-4 333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Iowa Orthopaedic Center, PC
Marvin H. Dubansky, MD
Marshall Flapan, Ml)
Sinesio Misol, MD
Joshua D. Kimclman. DO
Timothy G. Kenney, MD
Lynn M. Lindaman, MD
Jeffrey M. Farber, MD
Kvle S. Galles, MD
Scott A. Meyer, MD
Cassini M. Igram, MI)
Donna J. Bahls, MD
Jill R. Meilahn, DO
Jacqueline M. Stoken, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MD
Marshall C. Greiman, MD
Steven R. Hcrwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Hill, MD
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; S2.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85/4 April 1 995 181
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MD
Eugene Peterson, MD
Richard B. Merrick, MI)
Peter V. Bocscn, MD
Robert It. Updcgraff, MI)
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neck
Surgery, PC
Thomas .1. Benda, Sr., MI)
James W. White, MD
Craig C. Hcrther, MD
Thomas .1. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MD
Guy E. McFarland, MD
Thomas F. Viner, MD
Douglas E. Dawson, Ml)
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery >
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery > and Head and
Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7 th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Physical Medicine &
Rehabilitation
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice I). Schncll, Ml)
Farccduddin Ahmed, MI)
Arthur It. Scarlc, MD
Bogdan E. Krysztofiak, MI)
Rehabilitation Medicine Associates
William 1). dcGravcIlcs, Jr., MI)
Charles F. Denhart, MD
Marvin M. Hurd, MD
William C. Koenig, Jr., MI)
Karen Kicnker, MD
Todd C. Troll, MD
Lori A. Sapp, MD
Younkcr Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
Surgery
Wendell Downing, MI)
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Fort Dodge Medical Center, PC
Ralph E. Woodard, MI), FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, Ml), FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MI)
Steven G. Berry', MD
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matysik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary > Diseases
Advertising Index
Bernie Lowe & Associates 170
Blue Cross Blue Shield 183
Bud M ulealiy ’s Jeep/Eagle 174
Clarkson College 179
Dale Clark Prosthetics 142
Genesis Medical Center 160
Havvkeye Medical Supply 159
Heartland Health System 179
1MPAC 155
IMS Services 151
Medical Protective Company 163
Medical Records
Assistance Services 162
MMIC 184
Sketnp Clinic 178
Throckmorton Surgical Society 146
U.S. Air Force 179
182 Iowa Medicine Volume 85/ 4 April 1995
Iowal Medicine
THE PRESIDENT COM M E N T S
Farewell advice
This is my last column as your president
and I must thank everyone who helped
me during the past year, especially my
wife, Polly, who traveled with me and made me
believe she enjoyed it. Thanks also to the IMS
staff who helped make my job a little easier.
1 can’t relinquish this space without encour-
aging you one last time to stand up for our
principles with big government, big business
and the insurance industry. Physicians are a
force to be reckoned with if we arrive at a
consensus in our ranks.
During the past 30 years, government has
become consumed with process rather than
progress. The cost of “process” in our nursing
homes, extended care facilities and hospitals is
enormous.
An example is the paper forms
required of skilled nursing facili-
ties. For each patient admitted,
there are 18 separate forms. More
forms are being added. This began
with OBRA ’87 and has increased
each year.
Nursing homes have so many
forms to complete that they have
difficulty finding the time. In nursing homes,
there are 15 forms to fill out for each new
patient. Quarterly forms require additional time
and care plans are required each week for each
patient. No wonder the fastest rising segment of
Medicaid costs is nursing home care.
The truly unfortunate aspect of this situa-
tion is that none of this paperwork ensures
' patients are getting better care. They add to
costs and are only important to paper checkers.
Recently, I asked a nurse why nursing homes
don’t complain. She told me they have com-
plained, but that the bureaucrats don’t re-
spond.
This is why it is so important for every
physician to become involved at some level and
not leave it to the next person.
When you bring your concerns to the IMS
House of Delegates in the form of resolutions,
you educate your colleagues on the issues of
importance to medicine. You also might learn
whether your concern is shared by other phy-
sicians.
We can all do something to take responsibil-
ity for where medicine goes in the future.
During the past year, I at-
tempted to introduce various top-
ics that may lead to action or, at
the least, induce people to be-
come informed and write to legis-
lators. In the future, look around
in your own communities to find
opportunities to make our voice
heard.
Is there a light at the end of the
tunnel for physicians? I believe there is. Ar-
ticles and books are starting to appear which
indicate increased public awareness of over-
regulation of health care and other industries.
However, we must stay educated and in-
volved or we cannot hope to change things for
the better.
Thank you for the privilege of serving as IMS
president. It has been a memorable year. ED
Physicians are
a force to be
reckoned with
if we arrive
at a consensus
in our ranks.
James White, MD
Iowa Medicine Volume 85/5 May 1 995 191
Iowa [Medicine
IMS Update
AT A GLANCE
Governor Terry Bran-
stad has reappointed
James Caterine, MD and
Teresa Mock, MD to the
Iowa State Board of
Medical Examiners. He
has appointed Dale
Holdiman, MD of Sioux
City to replace George
Spellman, MD when Dr.
Spellman’s term expires.
— •
The 1995 Iowa Family
Practice Opportunities
Fair will be August 26 at
the Savery Hotel and
Des Monies Convention
Center. The event is
sponsored annually by
the UI College of Med-
icine and the Iowa Med-
ical Society.
•
Dr. Peter Wallace has
been nominated to serve
on the Iowa Hospital
Association Board of
Directors. Dr. Wallace is
vice president of med-
ical staff affairs at
Mercy Hospital in Iowa
City. The IHA is attempt-
ing to expand non-CEO
representation on its
board.
New UI emphasis on primary care
Changes in the University of Iowa College
of Medicine curriculum will place more
emphasis on primary care disciplines, Dr.
Richard Nelson told the IMS Board of
Trustees during a special meeting last month.
Dr. Nelson, associate executive dean at the
UI, also reported that 62% of the new College
of Medicine graduates are entering one of
four primary care disciplines and 34% are
staying in Iowa for residency training.
The IMS Board of Trustees meets annually
with UI officials.
House of Delegates survey
As of early April, 347 IMS member physi-
cians answering a recent survey, 240 physi-
cians prefer the IMS House of Delegates
meeting be held in Des Moines; 107 would
like to see the meeting rotate to locations
around Iowa.
With regard to the time of the meeting,
172 prefer a spring meeting and 87 had no
preference as to the time of year.
The 1995 House of Delegates was sched-
uled to receive a report regarding these sur-
vey results.
IMS Membership Directory verification
In early June, member physicians will
receive a letter which will verify their office
addresses, phone and fax numbers, etc. for
the 1995-96 IMS Membership Directory. The
directory will be distributed next fall to all
member physicians, hospitals, chambers of
commerce, etc.
Please watch for your verification letter
and return it promptly to IMS headquarters.
This is essential if the directory is to contain
the correct information about your practice.
In addition, IMS members may advertise
their practices in a special section of the
directory. This advertising section is intend-
ed for reference use by member physicians
making referrals and by the public needing
medical services.
For details on how to place an ad in the
IMS Membership Directory, call Jane Nieland
or Bev Corron at IMS headquarters, 515/223-
1401 or 800/747-3070. If you placed an ad in
last year’s directory, you will receive a renew-
al form.
Specialty Society Update
The IMGMA Spring Meeting was May 3-5 at the Des
Moines Marriott. Fritz Wenzel, executive director of
MGMA, spoke on the future of medical group man-
agement. Greg Ganske discussed his first 100 days in
Congress.
The transition to Medco Behavioral Health operating
the Medicaid mental health benefits for the state of
Iowa is causing concern among Iowa psychiatrists.
Problems with receiving approvals for inpatient ser-
vices have caused delays. Contracts sent to Iowa psy-
chiatrists have also caused concern. A task force has
been established to seek modifications. (For more on
this issue, see the Futures section of this magazine.)
The American Medical Directors Iowa Chapter held its
spring meeting at the Airport Holiday Inn. Morris
Green, MD, PhD, AMDA president spoke on anxiety in
the elderly. David Folks, MD spoke on depression in
the geriatric patient.
The Iowa Society of Anesthesiology held its annual
meeting Saturday, April 1. Over 70 physicians from
Iowa and Nebraska attended. Keynote speaker was
Norig Ellison, MD, president-elect of the American
Society of Anesthesiologists.
The Iowa Radiological Society held its annual meeting
April 1-2 in Iowa City. The program covered interven-
tional radiology and current trends in radiology.
The Iowa Society of Rehabilitation Medicine held its
spring meeting on Friday, April 7 in West Des Moines.
The program included a presentation on CHMIS.
The Iowa Academy of Otolaryngology was represented
at Iowa Medicine Day on March 22 by president Dean
Lyons, MD. Dr. Lyons discussed bills pending in the
legislature on statute of limitations and definition of
surgery.
192 Iowa Medicine Volume 85 / 5 May 1995
AMA-ERF contributors
Hospital administrators and IMSA mem-
bers donated $2,255 to the AMA’s Education
and Research Fund in honor of physicians on
Doctors’ Day. Following are the physicians
honored by contributors:
Harold Eklund, MD; R Josef Hofmann, MD;
Charles Crouch, MD; Nicholas Messamer, MD; R.
Bruce Trimble, MD; Philip Habak, MD; Robert
Schulze, MD; Paul Holzworth, MD; Bernard Hoenk,
MD; Clifford Rask, MD; Fred Carpenter, MD;
Thomas Foley, MD; Dean Ehrecke, MD; John
Zittergruen, DO; James Delperdang, MD; Thomas
Johnson, MD; Dennis Rolek, MD; Harold Miller, MD;
James Bell, MD; James Reed, MD; Ronald Moeller,
MD; James Kimball, MD; Robert Bannister, MD;
Joseph Veverka, MD; Dwayne Howard, MD; David
Howard, MD; David Wall, MD; Kathleen Foster-
Wendel, MD; David Gerbracht, MD; Eugene Foss,
MD; Kenneth Lyons, MD; Gordon Flynn, MD.
In memorium donations were given for: Dallas
Minchin, MD and Robert Foss, MD. Donations
were also given in honor of the Genesis Medical
Center in Davenport, North Iowa Mercy Health
Center in Mason City, Marshalltown Medical and
Surgical Center and the Scott County Medical
Society Alliance. E3
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Iowa Medicine Volume 85 / 5 May 1995 193
Iowa [Medicine
Futures
AT A GLANCE
At the AMA Leadership
Conference, the AMA
announced formation of
a formal alliance with
the Denver-based Medi-
cal Group Practice
Association. The groups
will remain autono-
mous with their own
governing boards but
will work together on
common legislative goals,
education, research and
consulting.
Key congressional Rep-
ublicans have endorsed
a sharp slowdown in
the rate of growth of fed-
eral health spending,
while agreeing to give
states almost total con-
trol of the Medicaid pro-
gram. They are con-
vinced states can deliv-
er a more efficient pro-
gram with less money
and have a plan to con-
vert Medicaid spending
to a system of block
grants.
AMA COMPILES MANAGED CARE STATISTICS FOR IOWA
With the assistance of IMS staff, the
American Medical Association has com-
piled the following Iowa information for
inclusion in its Reference Document on
Managed Care.
Demographic information
Iowa
US
Population
2,807.6
257,282.9
% population over 65
15.7
12.7
Per Capita Income
$19,329
$20,672
Physician marketplace
Iowa
US
Practicing physicians
3,337
439,390
Physicians per 1,000
1.19
1.71
Primary care per 1,000
.46
.58
Per capita spending on
physician services
$483.77
$687.44
Hospital statistics
Iowa
US
(Community hospitals)
Total beds
13,653
918,786
Beds per 1,000
4.9
3.6
% bed occupancy rate
58.0
64.4
Average hospital stay
8.1 days
7.0 days
Insurance coverage*
Iowa
US
% population with coverage
89.85
85.12
% population/private coverage
% population/other public
80.76
71.42
coverage
21.81
25.05
% population with Medicaid
8.53
11.33
% population with Medicare
12.90
13.38
Physician Groups
Iowa
US
Number of groups
Total number of physician
250
16,009
positions in groups
2,757
184,358
Mean (median) group size
11 (5)
12 (5)
% with HM0 contracts
65.0
76.5
% of revenues from HMOs
11.7
16.0
% of PP0 contracts
64.5
69.3
% of revenues from PPOs
13.4
15.6
List of group practices with over 100 physicians:
Iowa Clinic
* Numbers add
Iowa Physicians Clinic
up to over 100 %
McFarland Clinic
because some
University of Iowa College of Medicine
patients have
more than one
type of coverage
Medicaid managed care operational here
According to officials of the Iowa
Psychiatric Society (IPS), the Medicaid men-
tal health managed care contract being imple-
mented by Medco is now operational in Iowa,
and Iowa psychiatrists have been contacting
the IPS office with problems and concerns.
To date, problems have occurred with con-
tract provisions, operational difficulties such
as lack of telephone access and billing and
coding procedures.
However, patient concerns have been pri-
mary with many IPS members expressing
concerns regarding patient care issues and
difficulty in obtaining authorization to admit
patients to the hospital. In response to these
calls, the IPS office has established an inci-
dent file which will be discussed with Medco.
IPS officials have been told that criteria for
evaluating the success of the managed mental
health program will be based in part on the
number of appeals filed by doctors on utiliza-
tion review decisions.
Officers of the IPS met recently with Iowa
legislators and Medco representatives. At that
meeting, Medco representatives said they will
institute a Providers Round Table which will
meet every two weeks to discuss matters of
concern.
For more information on these issues, call
Dana Petrowsky, executive director of the
IPS, at 800/728-5398.
Scorecard of Iowa reforms
Following was the status of health system
reform initiatives in Iowa:
1. Purchasing reform — Enables individu-
als or small groups to combine purchasing
power, also known as IIIPGs. Implemented.
2. Delivery reform — Groups of providers
194 Iowa Medicine Volume 85/5 May 1 995
“You Asked for It! We Have It!”
I
Specialty
Coding
Extravaganza
RESCHEDULED DATES
Date: June 13 and 14, 1995
Time: 8:30 a.m. to 4:30 p.m.
Where: Best Western Des Moines International,
1810 Army Post Road, Des Moines
Because of unforeseen complications for our presenter, Nancy Maguire, we have decided to reschedule the program
to Tuesday, June 13, and Wednesday, June 14. Fortunately, Nancy Maguire and the Best Western Des Moines
International are available.
TUESDAY, JUNE 13, 1995— TERRACE ROOMS 1 & 2
8:30 a.m. to 4:30 p.m — PEDIATRIC AND PRIMARY CARE CODING
Don’t miss this opportunity to get the right answers to your difficult coding questions. This seminar will help you with
practical advice to avoid reimbursement pitfalls. Use E & M codes correctly the first time and avoid common mistakes.
WEDNESDAY, JUNE 14, 1995— TERRACE ROOM 4
8:30 a.m. to 4:30 p.m. — ALL SURGERY
Includes orthopaedic, neurosurgery, ENT and general surgical coding. You, too, can bill the right surgical codes every
time and avoid duplication and unbundling edits. Find out when to use those tricky modifiers. Discussion will be based
on actual operative notes.
COST:
1 full day: #175 for IMS member or staff, #280 for non-member or staff
2 full days: #320 for IMS member or staff, #530 for non-member or staff
For hotel reservations call the Best Western Des Moines International at
515/287-6464. Be sure to give the seminar name for special rates. Maps are
available upon request.
Continental breakfast, break
refreshments and lunches will
be furnished both days.
Registration Form
Specialty Coding Seminar — Registration deadline is June 1
Name(s):
Clinic/Practice Name:
Address: — __ __
Phone: Fax:
Amount Enclosed: Date:
Please make checks payable to IMS Services. Mail check and registration form to:
IMS Services, ATTN: Sherry Johnson, 1001 Grand Avenue, West Des Moines, LA 50265-3599
CURRENT ISSUES
combining in newly permitted ways to pro-
vide comprehensive services to consumers in
a capitated environment, called organized
delivery systems. Implemented.
3. Employer access — Employers are
required to provide workers with information
about where they can receive health benefits.
Rules being finalized.
4. Small group insurance reform —
Redefines small group to 2-50 individuals,
standardized benefit packages, changes in
rating practices, elimination of pre-existing
conditions, guaranteed access and portabili-
ty. Implemented.
5. Individual insurance reform — Provides
individuals with same protections afforded
small group insureds. Signed by governor.
6. Tax equity — Enables individuals to
deduct 100% of out-of-pocket insurance pre-
miums from state income taxes. Signed by
governor.
7. CHMIS — Electronic filing and billing,
data repository for health data collection.
Goes into effect for providers July 1, 1996.
8. Statewide health accounting system —
Enables detailed tracking of health care
income, expenditures and outcomes; request
for proposal has been issued to help establish
system. Authorized in 1994.
9. Report cards — IIIPGs required to pro-
duce their own; state required to provide on
ODSs. Implemented.
10. Telemedicine — Using transmission
networks to enable physicians in different
locations to consult on problems, particularly
useful in rural or remote areas. Implemented.
1 1. Recruiting and retaining providers —
Special efforts to attract health care providers
to particular areas of the state and induce-
ments for them to stay. Implemented.
12. Standard benefits package — Rules filed.
13. Medical liability reform (As of press
time, this was pending in the 1995 Iowa
Legislature) — Reduction in statute of limita-
tions for minors to six years plus two years.
14. Medical savings accounts — Pending in
1995 Iowa Legislature.
Managed care developments
The following information is provided by
the American Medical Association.
•For the third consecutive year, California
Public Employees Retirement System has
negotiated a premium reduction from 22
California HMOs. The 5.2% reduction for
1995-96 tops last year’s reduction of 1.1% and
brings premiums to their 1991 levels.
•The Foster-Higgins survey of employer
sponsored health plans found that in 1994,
the employer expenditure for health benefits
declined an average of 1.1%. In the Northeast,
a decline of 9.7% is attributed to a jump in
managed care enrollment from 34% to 63%.
•Upjohn has developed Greenstone
Healthcare Solutions, a disease management
unit offering hospitals and managed care
organizations programs to determine patient
health risk and optimal treatment options.
Pharmaceutical companies view disease man-
agement as a potential revenue source.
•A recent study of 20,000 consumers in 20
markets found that 83% of respondents in
HMOs are satisfied with their plans compared
to 77% in fee-for-service and 76% in PPOs.
However, IIMO patients were less satisfied
with access to referrals.
•PPOs reduced their physician panels by
an average of 8% between 1992-93 and cut
hospital contracts by 22%.
Gingrich calls for investigation
During the AMA’s recent Leadership
Conference in Washington, DC, House
Speaker Newt Gingrich called for a congres-
sional investigation of the managed care
industry, the fastest growing and most con-
troversial sector of the nation’s health care
system. Gingrich’s call for hearings was
cheered by doctors. Managed care is coming
under increasing fire for being dominated by
bean counters more concerned about the bot-
tom line than the quality of care.
Gingrich met privately with AMA officials
and he later expressed concern over anec-
dotes in the news about patients not receiv-
ing proper care. James Todd, MD, AMA exec-
utive vice president, said the AMA is “very
much in favor of hearings”.
Financing physician ventures
In this month’s Iowa Medicine feature on
page 202, Steve DeNelsky, senior financial
consultant with Medical Alliances in
Alexandria, Virginia, discusses financing of
physician managed care ventures — options
available and steps necessary to obtain
financing, id
Newt Gingrich
called for a
congressional
investigation of the
managed care
industry*
Iowa Medicine Volume 85 / 5 May 1995 195
Iowa | Medicine
Legislative Affairs
Key bills survive second funnel
AT A GLANCE
U.S. Representative Greg
Ganske has teamed
with an Oregon Demo-
crat to introduce legisla-
tion which would prohibit
patenting of medical and
surgical procedures. The
measure has the strong
support of the AMA.
•
President Clinton has
signed into law a bill
giving more than three
million self-employed
people the right to
deduct their health
insurance costs from
their taxes. Part of the
bill lets the self-
employed deduct 25% of
the cost of health insur-
ance premiums for
themselves and their
families.
The legislature is nearing the end of the
1995 session. Following is an update on the
status of key bills of interest to the IMS.
Statute of Limitations
The IMS statute of limitations bill passed
the House this year but was not brought out
of the Senate Judiciary Committee. It will
still be eligible for Senate consideration dur-
ing the 1996 session. The IMS plans to con-
tinue to work with senators on this issue.
Physicians are encouraged to meet with local
senators and discuss this and other issues
over the summer and fall.
Any Willing Provider
The “any will provider” bills are dead for
the session unless offered as amendments to
other bills.
Definition of Surgery7
The IMS bill to define surgery was killed for
the session. After approval by the Senate
Human Resources Committee it was referred
to the Senate State Government Committee
which failed to approve it.
LTniform Anatomical Gift Act — SF 117
The bill updating the Uniform Anatomical
Gift Act passed both houses and will be sent
to the governor for consideration. The bill
was initiated by the Iowa Statewide Organ
Procurement Organization which worked
with the Iowa Medical Society, the Iowa
Hospital Association and the Iowa State Bar
Association. SF 117 updates current Iowa
organ donation law which was adopted in
1983. More details about the new law will be
provided in the July issue of Iowa Medicine.
Trauma System — SF 118
SF 118 has passed both houses and is on its
way to the governor for approval. The bill
establishes a structure for a statewide trauma
designation system for hospitals. There will
be no restrictions on the types of services that
may be provided by any hospital. A Trauma
System Advisory Council consisting of physi-
cians, hospital representatives and other
health personnel will implement the plan.
The bill was developed by the Iowa Trauma
Systems Development Project Planning
Consortium in conjunction with the Iowa
Department of Public Health with the intent
of insuring the coordination of the various
components of Iowa’s trauma services.
Prior Authorization of Certain Prescription
Drugs Under Medicaid — SF 462
As a cost saving measure within the state’s
Medicaid program, the Department of Human
Services appropriation bill contains a require-
ment that for drugs where a generic bioequiv-
alent exists (using the FDA’s “A” list of gener-
ic bioequivalents) prior authorization will be
required for the brand name drugs.
Prior authorization will not be required for
the generic. IMS physicians have done a pre-
liminary review of the list to ensure that it
does not contain drugs where the brand name
is preferred for medical reasons. We will have
another opportunity to review the list in
detail during the administrative rulemaking
process. This provision will go into effect
September 1.
Reimbursement for Obstetrical Care — SF 462
Medicaid reimbursement for obstetrical
care will increase by 5% beginning July 1, if
SF 462 is approved in its present form.
Public Health Bills LTnsuccessful
This year was generally not a good year for
public health bills. Tobacco and motorcy-
cle/bicycle helmet bills received approval by
the Senate Human Resources Committee but
were all referred to less favorable committees.
Getting Tough on Drunk Drivers
Unlike most public health bills, SF 446,
which cracks down on drunk drivers, has
passed both houses; Governor Branstad has
196 Iowa Medicine Volume 85/5 May 1 995
CURRENT ISSUES
expressed support for SF 446 and is expect-
ed to sign it. It requires a 30-day license
revocation for underage drinkers (under 21,
the legal drinking age) who drive with a
blood alcohol concentration of 0.02% or
more.
Adults who are convicted of drunk driving
must lose their license, with no temporary
restricted permit allowed for at least 30 days.
Persons convicted of a second or subsequent
offense will have the vehicle they were dri-
ving impounded or immobilized with an igni-
tion interlock device for the period of license
revocation. Provisions are included to allow
family members who must use the vehicle.
The legislature wanted to send a message
that drinking and driving don’t mix.
Podiatrist Defined as Physicians
SF 152, renaming podiatrists as “podiatric
physicians” has passed both houses.
A complete review of final 1995 legislative
action will appear in the June issue of Iowa
Medicine.
Key facts about liability
•The medical liability system costs nearly
$50 billion a year, including $25 billion for
defensive medicine.
• Injured patients receive only 43 cents of
eveiy liability dollar. Lawyers get most of
what is left.
• Studies show that 60 to 75% of all
liability claims have no merit and are
settled with no compensation paid. This
drives up premiums. Even in cases without
merit, physicians often settle out of court
to avoid the expense and trauma of a trial.
• Nearly 40% of physicians (78% of
0B/GYNS) will have a claim against them
during their career, regardless of the
quality of care they provide.
• One of eight obstetricians has stopped
delivering babies because of the liability
system.
AMA scores liability victory in House
Guest editorial by Robert McAfee, MD
president, American Medical Association
On March 9, medicine scored one of its biggest legislative victories
ever when the House of Representatives, in a bipartisan vote,
approved an AMA-backed amendment that would place a $250,000
cap on pain and suffering awards in medical malpractice cases. This
historic vote came as a result of an all-out lobbying effort by your
American Medical Association and many other medical organiza-
tions. It was a blockbuster victory for the AMA, the medical profes-
sion and every practicing physician.
Liability reform has been at the top of medicine’s legislative agen-
da for as long as most of us can remember. Now, after 20 years of tire-
lessly campaigning, we can claim a major win in Washington.
However, the legislation still has to go before the Senate, where the
proposal is sure to be a prime target of the trial lawyers’ lobby. So, our
task is only half complete. The vote there is likely to take place in the
next few weeks and we are asking all of you to contact your senators
and let them know where you stand.
Here are some of the things the AMA has done:
•We’ve mobilized state, county and national specialty societies to
join our effort. In late March, we sent a letter to every Senator that
was signed by the medical societies in all 50 states and by 81 spe-
cialty societies. AMA Alliance sent letters to every county legislative
chair in home districts of the Senate Judiciary Committee members,
urging them to call and fax their support for liability reform.
•We’ve gone directly to Capitol Hill. During our National Leader-
ship Conference in Washington, we held a reception for members of
Congress and followed that up with one-on-one visits by physicians.
•We’ve gone public through drive-time ads on Washington’s top
radio stations, rebutting scare tactics used by trial lawyers. We’ve
placed ads in major newspapers.
The public is listening. A Gallup survey showed more than 71% of
Americans favor liability reform, including caps on pain and suffering
awards. Clearly, many of our patients are on our side, but we can take
nothing for granted.
Tell your patients. Tell your colleagues. Tell your representatives
in Congress. The AMA and organized medicine are leading the more
than 700,000 physicians of America in the battle for liability reform.
Congress must know we will not stop until the job is done.
As this is being written, liability reform is at the top of our priori-
ties. But Medicare reform and the AMA’s 1995 Patient Protection Act
will also receive attention in the coming days and months.
Together, organized medicine is fighting for legislation that will
allow you to care for your patients to the best of your ability and con-
science. I invite all of you to join us in that fight. E3
For materials suitable for sharing with patients, call the AMA at
312/464-4430.
Iowa Medicine Volume 85/5 May 1 995 197
Iowa [Medicine
Medical Economics
AT A GLANCE
Since Oregon passed the
nation’s first physician
assisted suicide law, 12
other states have plan-
ned or introduced simi-
lar legislation. A federal
court last month ruled
that states can ban doc-
tor-assisted suicide.
Most feel this issue will
be resolved by the
Supreme Court.
•
As of press time, the
AMA was celebrating a
big victory following a
vote by the Republican
controlled House to limit
pain and suffering dam-
ages in medical mal-
practice cases to
S 250,000 . Lawmakers
voted to include the cap
as part of a broader bill
to limit the amount
plaintiffs can collect in
product liability suits.
•
It will be easier for
employers to change or
cancel retiree health
benefits because of a
recent Supreme Court
riding. The justices said
standard benefit plan
wording giving compa-
nies the right to amend
a plan is valid.
CHMIS activities update
The Iowa Medical Society’s Ad Hoc
Committee on CHMIS met April 4 to hammer
out recommendations on CHMIS policy. The
committee’s final recommendations were
scheduled to be considered by the IMS House
of Delegates April 29-30.
Under the CHMIS law, by July 1, 1996, all
health care providers must submit claims
electronically using a standard format and all
payers will be required to accept the standard
format. However, many details regarding how
the CHMIS will work have not yet been deter-
mined by the state CHMIS Governing Board
and five advisory committees.
The focus of the April meeting was discus-
sion of IMS policy regarding implementation
of CHMIS, Phase I in July of 1996.
The recommended IMS policy was devel-
oped in response to physician concerns with
confidentiality of patient-specific medical data
and the cost to physicians to implement,
maintain and participate in CHMIS. The poli-
cy also provides guidance for IMS representa-
tives on the five CHMIS advisory committees.
Other points in the proposed policy deal
with network certification, coordinating all
data collection through CHMIS and maintain-
ing a phased in approach to CHMIS in Iowa.
However, the most critical issues continue
to be cost/financing decisions and confiden-
tiality protection.
Several committee members emphasized
the importance of physicians staying involved
in the CHMIS implementation process to
ensure that data about physician practices is
used appropriately. This participation will
also keep IMS in a position to determine what
physician data needs will be in the future and
and how these needs can be met.
IMS staff and physicians have presented
close to 30 CHMIS programs around Iowa.
Special programs on CHMIS are available for
any group of member physicians. To schedule
a program, call Ed Whitver, 515/223-1401 or
800/747-3070.
Ambulatory Care Quality Improvement
The Iowa Foundation for Medical Care
(IFMC) has begun a two-year project under
its contract with IICFA. The project is called
the Ambulatory Care Quality Improvement
Project (ACQIP).
ACQIP focuses on collaborative efforts to
refine and implement educational and out-
reach strategies to improve ambulatory care.
The project’s purpose is to profile practices of
care for physician self-examination through
information sharing.
Iowa, Alabama and Maryland physicians
will evaluate primary and preventive services
provided through physician offices to
Medicare beneficiaries with diabetes. Mary
Nettleman, MD and Richard Osterholm, MD
represent Iowa on the national HCFA panel
which will develop quality indicators for dia-
betes. A local Iowa study group has also been
formed. This group includes IMS members
Steven Craig, MD, Des Moines; John Olds,
MD, Des Moines; and Milton VanGundy, MD,
Marshalltown.
Primary care physicians will be selected
1995 Medicare premiums,
DEDUCTIBLES AND COINSURANCE
Medicare Part A
PREMIUM: $261 per month for regular entitlement
$183 per month for reduced premium
DEDUCTIBLE
Hospital: $716 per benefit period
COINSURANCE
Hospital: $179 per day (61st through 90th day)
$358 per day (each “lifetime reserve” day)
SNF: $89.50 per day (21st through 100th day)
Medicare Part B
PREMIUM: $46.10 per month
DEDUCTIBLE: $100 per calendar year
COINSURANCE: 20% of Medicare allowed amount
198 Iowa Medicine Volume 85 / 5 May 1995
CURRENT ISSUES
from Medicare claims data and requested to
provide identified medical records for review.
IFMC will do the review this fall. Physicians
will not need to retrieve data from the
records and will be reimbursed for copying
and mailing.
Profiles will be created from claims data
and sent to volunteer physicians, followed by
educational activities. Medicare claims and
physician office records will be reviewed to
assess the impact of educational efforts
regarding care of persons with diabetes.
If you are interested in participating in this
project, call Mary Schrader at the IFMG,
800/373-2964.
The death of common sense
— anger and frustration. The reason, he
learned, is that “we’ve banned judgment”.
The book cites many examples of govern-
mental regulation such as OSIIA which have
given bureaucrats almost “limitless arbitrary
power”. The GOP Contract With America,
Howard says, takes only small steps toward
true reform.
IFMC election results
The results of the Iowa Foundation for
Medical Care Board of Directors elections
have been announced. Nine directors taking
office immediately for three-year terms are:
COUNTY REPRESENTATIVE
Cerro Gordo Michael Crane, MD, Mason City
A new book called “The Death of Common
Sense”, which decries the amount of govern-
mental regulation in this country, is a run-
away bestseller.
The book’s author, Phillip Howard, says he
wanted to figure out why everyone who deals
with the government has the same reaction
Des Moines
Johnson
Linn
Polk
Pottawattamie
Story
District I
District VII
Koert Smith, MD, Burlington
Karl Larsen, MD, Iowa City
Jolynn Glanzer, MD, Cedar Rapids
Peter Boesen, MD, Des Moines
Gary DeVoss, MD, Council Bluffs
Elie Saikaly, MD, Ames
John Ellis, MD, Marshalltown
Stephen Piercy, MD, Fort Dodge DZ3
BE AN AIR FORCE
PHYSICIAN.
Become the dedicated physician you
want to be while serving your country in
today’s Air Force. Discover the tremen-
dous benefits of Air Force medicine. Talk
to an Air Force medical program manag-
er about the quality lifestyle and benefits
you enjoy as an Air Force professional,
along with:
• 30 days vacation with pay per year
• Dedicated, professional staff
• Non-contributing retirement plan if
qualified
Today’s Air Force offers the medical envi-
ronment you seek. Find out how to quali-
fy. Call USAF HEALTH PROFESSIONS
TOLL FREE
1-800-423-USAF
Iowa Medicine Volume 85/5 May 1 995 199
Iowa [Medicine
Practice Management
CURRENT ISSUES
AT A GLANCE
Don’t miss this month’s
feature article on page
202 for some valuable
advice on how to obtain
financing for physician
managed care ventures.
•
According to an article
in AM News, physicians
should become ac-
quainted with certain
business skills in order
to survive in the world
of managed care. The
most important is learn
to negotiate. Physicians
have economic clout
because they control
patient care. Physicians
are advised not to be
intimidated by lawyers
or MBAs — everything is
negotiable, from con-
tracts to compensation.
Seminar discounts!
IMS Services has slashed prices for one
class this year (per person) from 111 50 to $99.
For purposes of this special offer, choose from
Medical Terminology in June, Quality in the
Medical Office in September or Billing and
Collection Strategies in October.
Look for a discount coupon in the mail in
early May for June classes listed in the box
below. For more information, call Mary
Reinsmoen at IMS Services, 800/728-5398.
Medical Business Specialist program
The first year of the Medical Business
Specialist certificate program has been com-
pleted. This successful program is meeting
the needs of staff in many physician offices
across Iowa and the program continues to
grow. For more information, call Mary
Reinsmoen or Sherry Johnson at IMS
Services, 800/728-5398.
Retirement readiness
There is still time to register for a seminar
on retirement readiness scheduled for May 24
at IMS headquarters in West Des Moines. The
seminar, designed for physicians and their
spouses, answers important questions for
physicians as they plan for retirement.
For more information, call Mary Reins-
moen at 800/728-5398. [EH
Midwest Medical Insurance
Focus on Risk Management
Communicating after a bad outcome
A bad outcome during the course of med-
ical care is distressing to the patient and the
physician. It can be difficult for a patient to
understand that a bad result does not auto-
matically imply negligence.
How do you apologize to a patient after a
bad outcome in a way that does not admit lia-
bility or negligence? How do you discuss the
situation without saying “It’s my fault”? How
do you say “I’m sorry” without saying “I’m
liable”?
An expression of sorrow and an explana-
tion of the bad outcome need not imply
either personal responsibility or negligence.
While it may not prevent a malpractice
claim, an honest, empathetic discussion of
the problem within a reasonable time often
helps soothe a patient’s anger and distrust.
These situations can be extremely difficult
to handle and there is no simple rule to fol-
low. The best advice is to call legal counsel
and your professional liabilty insurer for
guidance. Any wrongdoing you admit to a
patient or a patient’s family may be used in
court.
For further information, contact Lori
Atkinson, MMIC risk management coordinator,
MMIC West Des Moines office, PO Box 65790,
West Des Moines, 50265, 800/798-9870 or
515/223-1482.
Upcoming IMS Services seminars for you
* Medical Terminology
Wednesday, June 7
WEST DES MOINES
Wednesday, June 14
SIOUX CITY
Thursday, June 22
CEDAR RAPIDS
* Office Team Skills
Thursday, June 8, WATERLOO
Wednesday, June 21, DAVENPORT
Wednesday, June 28
WEST DES MOINES
Thursday, June 29, SIOUX CITY
*These seminars are part of the
IMS Medical Business Specialist
(MBS) certificate program
For more information on any seminar, call Mary Reinsmoen or Sherry Johnson at the IMS, 515/223-1401 or
800/728-5398.
200 town Medicine Volume 8.5 /.5 Mn.v 799.5
Iowa| Medicine
CURRENT ISSUES
Newsmakers
Awards, appointments, etc.
I)r. Franklin Scamman, associate professor
in the Department of Anesthesia, UI College of
Medicine and chief of Anesthesiology Service at
the Iowa City Department of Veterans Affairs
Medical Center, has been named the first direc-
tor of the newly established National Anesthesia
Service for the Veterans I Iealth Administration
in Washington, D.C. lie will direct the national
activities from the Iowa City VA Medical Cen-
ter. Two UI College of Medcine, Department of
Internal Medicine faculty have received Estab-
lished Investigator Awards from the American
Heart Association: Dr. Kevin Dellsperger, as-
sociate professor and Dr. Kathryn Lamping,
assistant professor. A photo of Dr. Enfred
Linder’s daughter, Dr. Jo Ellen Linder, ap-
peared in the February issue of LACMA (Los
Angeles County Medical Association) Physi-
cian magazine. Dr. David Sommerfeld, medical
director of the Ottumwa-Henry Kidney Dialysis
Facility, has been certified as a diplomat of
nephrology by the American Board of Internal
Medicine. Dr. Merlin Osborn, anesthesiolo-
gist, has retired after practicing in Cedar Rapids
for 27 years. Dr. Caroline Carney, Iowa City
resident physician, has received the National
Institute of Mental Health’s Outstanding Resi-
dent Physician Award. She was chosen from a
nationwide pool of applicants nominated by
their residency programs. Dr. Mark Dillon,
Ottumwa, has begun practice with Internal
Medicine, P.C. Dr. Lester Yen recently became
a diplomate with the American Board of Plastic
Surgery. Three longtime anesthesiologists as-
sociated with Mercy Hospital Medical Center,
Des Moines have retired: Dr. Donald Sweem,
Dr. Charles Hull and Dr. Marvin Silk. Dr.
Timothy Ryken, chief resident in the Division
of Neurosugery, UI College of Medicine, has
been named the 1995 VanWegenen Fellow by
the American Association of Neurological Sur-
geons. Dr. Donald Berg, orthopedic surgeon
with Ottumwa Regional Health Center, has
been elected president of the medical staff. Dr.
Debra Miller, pediatrician, is immediate past
president; Dr. Mark Leding, anesthesiologist,
is president-elect and Dr. Kurt Anderson,
otolaryngologist, is secretary. Dr. Jeffrey
Bittner, obstetrician and gynecologist with
Ottumwa Medical Clinic, has become board
certified by the American Board of Obstetrics/
Gynecology.
Here Comes Doctor Ward: A Climb to Glory
A book about Dubuque general surgeon, Dr.
Donovan Ward, is now available from Chicago
Spectrum Press. The book, entitled Here Comes
Doctor Ward: A Climb to Glory >, was written by
Howard Cartwright (formerly executive direc-
tor and CEO of the College of American Pa-
thologists) and reviewed by Dr. Marion Alberts,
Iowa Medicine scientific editor.
The author tells Dr. Ward’s extraordinary
life story in an interesting way from his child-
hood through medical practice and on to his
AMA presidency.
Dr. Ward has not only given much of his time
and talent to the medical profession, but also to
various civic organizations. He has worn many
hats: banker, navy lieutenant commander, river
pilot, talk show host, writer, musician, consult-
ant and entrepreneur.
The author sums up Dr. Ward in this way:
“Donovan Ward’s life story is a reminder that
there are heroes in the cities and towns across
America who should be heralded for being role
models for everyone whom they meet. This
book highlights Dr. Ward’s remarkable life, the
life of a true American hero.”
The narrative is enhanced by numerous
sidebar comments by Dr. Ward which makes
this book very enjoyable. It is available for $25
by calling Spectrum Press at 800/594-5190.
Deceased member
Roy Brackin, MD, 93, general surgery/fam-
ily practice, Oskaloosa, died December 24 Hu]
AT A GLANCE
The IMS domestic vio-
lence videotape that was
shown at the House of
Delegates on Sunday,
April 30 is now available
on a loan basis. Call Chris
McMahon, director of
communications, at 800/
747-3070 or 515/223-
1401 for details.
•
Dr. Greg Ganske, U.S.
Representative and Des
Moines plastic surgeon,
plans to do charity work
at Broadlawns Medical
Center. Dr. Ganske has
been granted temporary
staff privileges at Broad-
lawns and will volunteer
when he’s finished with
his congressional duties.
irto \Zr'il nm o ^ AAn\t 7 00^ 901
Iowa 1 Medicine
FEATURE ARTICLE
Financing of
Physician ventures
As soon as physicians decide which managed care model is
die most advantageous, the major obstacle is often securing
appropriate financing. The author discusses how to obtain
financing for physician-led business ventures and what it takes
to be successful in today’s marketplace.
Steve DeNelsky
Steve DeNelsky is a
senior financial
consultant with Medical
Alliances in Alexandria,
Virginia. He specializes
in physician integration,
business valuation,
mergers and acquisitions.
He writes a monthly
column in the magazine
Group Practice Managed
Health Care News.
The health care marketplace in the United
States is changing in ways unimaginable just
twenty years ago. Once, managed care was
for renegade physicians who believed in
unconventional wisdom; today it is becoming
a matter of financial survival. For physicians,
the debate has shifted from whether a
significant portion of Americans will receive
care under a managed care system (a
foregone conclusion) to what managed care
model is the most advantageous.
Physicians are forming many types of
ventures, ranging from two independent solo
practitioners merging to a large group of
physicians developing a health care delivery
system employing hundreds of physicians
and serving thousands of patients in multiple
states. While virtually all organizations can
map out some rough goals,
strategic objectives and a vision,
most of these infant firms will
have trouble growing and fulfilling
their objectives. Reasons for busi-
ness failures are usually multiple
and may include lack of
leadership, management culture
clashes and flawed strategy.
However, most entrepreneurs concur that
the most daunting obstacle facing a new
business is securing appropriate financing.
Physicians in optimal position
Obtaining financing for a physician-led
organization can be troublesome. Many of
these corporations are more common than a
cold and have many difficulties differentiating
themselves in a marketplace over saturated
with entities born from a reactive impulse to
thwart the managed care movement.
On the bright side, there are millions of
dollars waiting in the wings for the “right”
managed care development projects and
physicians are in an optimal position to tap
this pool of money. All indications point to
tremendous interest from private
financing companies, existing
health systems and the public in
funding physician-led ventures.
Most people are aware of the
common investment principle that
the reward of an investment
should be commensurate with the
There are millions
of dollars waiting
for the “right”
managed care
development
projects.
202 Iowa Medicine Volume 85/5 May 1 995
FEATURE ARTICLE
risk. Unfortunately, rules governing financing
are far less lucid. The type of financing an
organization employs should depend on
current and future investments. In addition,
financing methods should always be matched
to the firm’s particular investment oppor-
tunities and not the other way around.
What will the market bear?
Companies face different financing
opportunities according to what the market
will bear. Different financing is available
depending upon variables such as which
products or services will be sold, the firm’s
size and past performance. Especially among
smaller entities, the quality of top
management can be a factor in determining
the spectrum of financing options.
While a plethora of factors shape the
financing horizon, they can be whittled down
to one all encompassing element — Will the
financier receive a fair return on the
investment, given the level of risk compared
to other opportunities available in the
marketplace? Any company trying to locate
financing should be able to provide many
reasons why the answer to this question is
“yes”.
Internal funding
Internal funding of investment oppor-
tunities is the easiest and quickest method of
raising capital. Internal funds, or retained
earnings, account for between one half and
two thirds of long-term corporate financing.
When a project is earmarked for internal
funding, money is simply diverted from the
company’s cash flow to the investment
opportunity. While this type of funding is less
expensive, it is by no means “free” financing.
If a corporation uses retained earnings to
finance an endeavor that loses money, the
value of the corporation will decline.
Professional corporations such as indepen-
dent medical practices usually distribute all
earnings to their members on a year-to-year
basis. Because of this, these businesses
typically do not possess a well of retained
earnings to fund new ventures. While funds
can be budgeted from the practice towards
new projects such as mergers, diversification
of capital is tantamount to physicians making
an outside investment in their practice, since
earnings in that year will decline.
The major advantage of internal funding is
that physicians do not have to relinquish
control of the business. The disadvantage is
that if the project fails, their money will fail
also and will never be recouped.
At some point, most companies will find a
worthwhile investment opportunity that, due
to the required fiscal outlay, cannot be
financed through retained earnings. In these
situations, a company can look to alternative
sources of financing. .. ,
0 nrm tin'll
The major
advantage of
internal funding is
physicians do not
have to give up
control of their
business.
Iowa Medicine Volume 85/5 May 1 995 203
Iowa | Medicine
FEATURE ARTICLE
continued
Joint ventures can
also fee termed
around manage-
ment expertise,
marketing channels
or access to
primary care
physicians.
Strategic alliances and joint ventures
A strategic alliance is a formal relationship
between two or more entities arranged to
accomplish common goals. A joint venture is
similar to a strategic alliance but carries a
higher level of legal integration between the
parties because a new legal entity is formed.
The impetus behind joint ventures is
theoretically very appealing. Each company
involved has a strategic advantage in a
particular area and they decide to cooperate
to achieve common goals.
In many instances, a company will provide
or receive some degree of financing through
a joint venture. However, joint ventures can
also be formed around management exper-
tise, marketing channels or access to primary
care physicians.
A strategic alliance or joint venture is an
easily-arranged business endeavor; but, for a
variety of reasons, most eventually fail.
Many physician-led joint ventures fail due to
a lack of management expertise. Also, when
one party is the key source of money for the
venture, the lines may blur between a true
“joint” venture and a simple investment.
This scenario provides fertile soil for
divergent expectations and disagreements on
control within the venture.
AMA Capital Funding project
The American Medical Association has
recently initiated a program designed to pair
physician-led ventures with potential
financing sources. The program, Physicians
Capital Source, is intended to let physicians
help design health care delivery systems that
can compete against insurers and other
investor-owned health organizations.
The AMA will help physicians develop
business plans and build skills necessary to
rival non-physician organizations and secure
financing to fuel future growth. In addition,
the AMA would like to create an “AMA
University” where physicians can attend
courses to learn about the fundamentals of
managed care and get their business plans
reviewed by investors.
(For more information on this new AMA
project, see page 206.)
Venture capital and private equity firms
Venture capital or private equity firms are
other avenues that can be used to finance a
company’s investment objectives. Many
companies that use venture capital as a
financing source may not be able to secure
other types of financing because of the
company’s current financial position. Prime
candidates for venture funds are firms which
are years away from being able to tap the
public equity or debt markets and desire
more capital than many traditional private
sources, such as banks, would care to risk.
The 2,000 or so venture firms operating in
the U.S. provide funds in many different
stages of a company’s growth — from seed-
money to bridge financing. The venture
firms usually demand some control in the
business that is receiving the financing. In
204 Iowa Medicine Volume 85/5 May 1 995
FEATURE ARTICLE
addition, since venture firms usually invest
where their partners have management
experience, these firms can provide valuable
expertise as well as much needed capital.
Public equity
There has been a proliferation of public
stock offerings used to finance companies
over the last 10 years. A primary reason for
the increased use of the equity markets is
that individual investors, largely through the
use of mutual funds, have pumped money
into stock markets at an unprecedented rate.
While Phycor and Pacific Physician
Services may be grabbing headlines for their
soaring stock prices, many other health care
companies do not have what it takes to
attract serious attention from either the
public or investment bankers. Most comp-
anies need at least $150 to $200 million in
sales, a predictable growth curve and, most
importantly, a management team that can
lead the future growth of the company.
Many other financing methods
The methods described account for a large
percentage of the dollars raised by health
care firms, but just scratch the surface in
terms of the number of financing possi-
bilities. The increase in prepaid contracts for
medical care should let physician-based
groups with steady and predictable revenue
streams use the debt markets with more
frequency. Nonprofit entities may be able to
issue tax-exempt bonds, which basically give
the issuing firm a government subsidy that
lowers the total cost of financing. High-yield
debt financing is possible for companies with
less than stellar credit ratings.
Private placements, preferred stock
offerings, convertible bonds and even
employee buyouts are all viable means to
finance physician-led ventures and shape
the health care industry of tomorrow.
Match the financing to the investing
There is no one best way to finance a
company. There are many factors that firms
should consider when contemplating
financing decisions. The size of the firm,
cost of capital and current market
conditions are all important. Since the
money raised from financing activities will
ultimately be invested, it is vital for a firm to
adequately match the cash flow between
financing and investing.
Raising money is an important function of
any firm. Choosing a financing method is an
integral part of a company’s existence and
should be done carefully and realistically.
While nothing guarantees success in today’s
turbulent health care marketplace, a comp-
any will have a better focus when financing
decisions are designed on operational
strategies instead of strategies being built
around available financing.
Private placements,
preferred stock
offerings,
convertible bonds
and employee
buyouts are viable
means to finance
physician-led
ventures.
Iowa Medicine Volume 85/5 May 1 995 205
Iowa[ Medicine
AMA’s Physicians Capital Source Program
“Quality-first” health care delivery
The American Medical Association has created
Physicians Capital Source, a program designed to
help physicians build and lead “quality-first” health
care delivery networks. This new program gives phy-
sicians access to managed care, business, financial
and legal experts who can help them develop business
plans and links them with potential capital sources.
Many physicians lack experience in forming their
own health care organizations and networks. Those
who are interested and have sound business plans find
it difficult to obtain financing. Beginning in 1990,
banks, venture capitalists and other investors began
to realize the financial viability of physician ventures.
The first step for physicians participating in the
Physicians Capital Source Program is the completion
of a Request For Information (RFI), which serves as a
blueprint for developing a business plan. The program
seeks business plans that focus on physician direction in
patient care, medical decision-making, allocating re-
sources and policy-making. Plans should also stipulate
that physicians invest in and share the risk in the venture,
as well as serve as members of the board of directors.
Physicians whose plans are approved are then linked
to potential capital sources that can meet their short
and long-term financing needs.
Advisory committee
The Physicians Capital Source Advisory Committee
is a national panel composed primarily of consultants
who develop health care ventures and entities that
finance these ventures. Its 61 members also include
related health care entities such as Blue Cross plans,
medical clinics, a health maintenance organization,
foundations and experts in information technology.
Members of the advisory committee offer partici-
pants advice and counsel during the application pro-
cess and evaluate completed business plans to deter-
mine if they are viable.
For more information on Physicians Capital
Source Program , call the AMA’s managed care
help line at 800/AMA-1066.
Physicians
Capital
Source
American Medical Association
Physicians dedicated to the health of America
206 Iowa Medicine Volume 85/5 May 1 995
r
i
Mroieapolis
• n /
Dubuque*
You’ll be glad
you found Monroe
Our safe, family-centered community of 10,000 is just
one hour from Madison, WI, Dubuque, IA and Rockford,
IL...two hours from Chicago and Milwaukee.,, and number 23
in 100 Best Small Towns in America. But the 50+ physicians
in our multispecialty group practice rank Monroe number one.
That’s because of the town's friendly spirit, four-season cli-
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at The Monroe Clinic — a consolidated, integrated healthcare
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Iowa [Medicine
SCIENCE AND EDUCATION
The Journal
of the Iowa Medical Society
Hepatitis B vaccination: a cost analysis
# George Bergus, MD; Steven Meis, MD
In November of 1991 the Centers for Disease
Control (CDC) recommended all infants be
immunized against hepatitis B. Universal
infant immunization promises to eliminate or
greatly reduce the incidence of hepatitis B
virus (1IBV) infection and its sequela of cirrho-
sis, hepatic cancer and death. The American
Academy of Pediatrics and the American
Academy of Family Physicians endorsed this
recommendation . 1-5
Despite these endorsements, many physi-
cians have concerns about the wisdom of
universal infant IIBV immunization/”9 For
some physicians, infant HBV immunization
does not have great immediacy because most
infections in the U.S. occur after age 15
years. Other physicians feel uncomfortable
subjecting infants to yet another series of
injections. Negative attitudes are especially
common in areas with low risk of infection
such as Iowa where the annual attack rate is
approximately 2 cases per 10,000 population
compared to the national rate of 12 cases per
10,000.10u
Cost-effectiveness analysis can help physi-
cians decide whether an intervention has suf-
ficient effectiveness at an affordable cost.
Most new preventive interventions such as
universal IIBV immunization do not promise
to reduce health care costs but should pro-
long life at a cost similar to preventive inter-
ventions presently in widespread use. Cost-
effectiveness studies on the use of hepatitis B
vaccination in high incidence populations
clearly justify programs to immunize high
risk populations.1215
Our study examines the cost-effectiveness
of universal HBV immunization using Iowa
data and calculates the cost for each year of
life saved from implementing a routine vacci-
nation program.
HBV immunizations
Efficacy of the full vaccination series is esti-
mated from randomized and historical clinical
trials and is assumed to be 95% for adolescents,
95% for neonates born to HBV negative moth-
ers and 7 5% for neonates bom to HBV positive
mothers. Anyone not completing the full three
shot vaccination series is considered nonim-
munized and susceptible to HBV infection.
Booster immunization against HBV is not
included in the model because we assumed
that individuals who were successfully immu-
nized had permanent protection from the vac-
cine. Although antibody titers are known to
decrease over time, there is little epidemiologic
evidence that these decreases are associated
with significantly reduced protection from
HBV. Immunized persons who have lost mea-
surable titers of hepatitis B surface antibody
might be at risk of infection but in large case
series few of these people succumb to infection
with jaundice and none have gone on to devel-
op chronic hepatitis.1617
Costs
For our study, we used the current hepatitis
B vaccine cost to our institution, $26.25 for the
three shot infant series and $86.40 for the ado-
lescent series. We did not include the cost of
office visits.
Costs of treating the sequela of HBV infec-
tion were taken from a review of the literature
and data from medical insurers.18 Costs are
discounted at 5% per year. Discounting years of
life remains a controversial issue in cost-effec-
tive analysis and are not discounted in most of
our analysis. 192,1 However, for the sake of com-
parison to some other published studies on
preventive interventions, we also calculated
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
May 1 995.
George Bergus, MD
Dr. Bergus is with the
University of Iowa
Department of Fam ily
Practice.
Steven Meis, MD
Dr. Meis is a fam ily
physician in LeMars.
Iowa Medicine Volume 85 / 5 May 1995 209
Iowa (Medicine
Hepatitis B vaccination: a cost analysis
continued
the cost-effectiveness of routine infant immu-
nization using discounted years of life.
Results
In Iowa, routine infant immunization
against hepatitis B should prevent 48.7 cases of
infection per 10,000 newborns saving a total of
52 years of life. The cost per year of life saved
is $2,970 when routine neonatal I1BV immu-
nization is added to the current program of
screening all pregnancies.
Immunizing all Iowans as teenagers, except
individuals born to mothers known to be
infected with HBV who will continue to be
immunized at birth, will be more costly than
immunizing all newborns. Teenage immuniza-
tion will also be less effective than universal
infant immunization in preventing serious
hepatitis B sequela because newborns bom to
unscreened hepatitis B mothers will not be
vaccinated. The cost for each year of life saved
using teenage immunization is $11,549. This
intervention prevents 32.4 cases of HBV per
10,000 persons saving a total of 21 years of life.
A third possible strategy is to institute
infant immunization with a second net to
catch nonimmunized children entering junior
high. This program has the highest effective-
ness but, because of a higher expense than
infant immunization alone, the cost per year
of life-saved rises to $3,934. This strategy
would prevent 58 cases and save 56 years of
life per 10,000 persons.
Discussion
Our analysis suggests universal infant
immunization is attractive from both clinical
and economic perspectives. Routine infant
immunization will reduce cases of chronic
hepatitis and therefore lost years of life at a
cost of $2,970 per year of life saved. This
compares favorably with other widely used
preventive health intervention as shown in
Tables 1 and 2. Although Iowa and other
states with low HBV attack rates pay a higher
price for each episode of HBV infection avert-
TABLE 1
COST PER YEAR OF LIFE SAVED FOR SELECTED MEDICAL INTERVENTIONS WITH
COSTS DISCOUNTED BUT YEARS OF LIFE NOT DISCOUNTED
Intervention
Cost per year of life save, $
Routine infant HBV immunization in Iowa 2,970
Beta-blockers after myocardial infarction 2,700
Pneumococcal vaccine (> 65 years old) 6,000
Cholesterol reduction: oat bran 8,500
: cholestyramine 35,250
Adapted from Bloom B, et a I.16
TABLE 2
COST PER YEAR OF LIFE SAVED FOR SELECTED MEDICAL INTERVENTIONS WITH BOTH
COSTS AND YEARS OF LIFE DISCOUNTED
Intervention Cost per year of life saved, $
Routine infant HBV immunization in Iowa 41,906
Colon cancer screening at age 65
annual fecal occult blood test 35,05426
adding flex sigmoidoscopy every 3 years 42,89229
Breast cancer screening in 55- to 65-year-old women
:annual breast physical exam 15.53627
:annual mammogram with exam 83.83030
Hypertension: detection and treatment in 40-year-old males 16,258“
INH chemoprophylaxis for recent PPD converter 35, Oil29
Cholesterol reduction using cholestyramine in 55-year-old males 117, 40030
Tetanus booster every 10 years 146, 13831
Pap smear every year compared to every 2 years in women at average risk of cervical cancer >1,000,00032
210 Iowa Medicine Volume 85 1 5 May 1995
SCIENCE AND EDUCATION
ed, routine HBV vaccination remains a cost-
effective strategy.
While most IIBV infections occur during
adolescence and adult life, routine infant
immunization is more cost-effective than ado-
lescent immunization because the risk of
chronic hepatitis is much higher for the
acutely infected infant. Nationally, only 1% of
acute HBV infections occur prior to adoles-
cence although these early infections account
for 20-30% of chronic HBV disease in adults.-1
Our analysis is influenced by a number of
the assumptions made in the model. The
price of the vaccine is a major driving force.
We used the vaccine cost at our institution
i and small volume purchasers might face a
higher price. It is likely, however, that as
production increases to meet the demand of
universal immunization and as health care is
regionally organized under health care
reform we will see the price drop. It is also
possible that the cost of immunization will
decrease due to research on alternate vac-
cine delivery methods that allow smaller dos-
es to be used.22
Based on our analysis, immunization of all
infants against HBV, as recommended by the
GDC, is affordable for Iowa although at a high-
er cost per year of life saved than for the
nation as a whole. Routine HBV immuniza-
tion of Iowa’s infant population compares
favorably to many other preventive interven-
tions physicians presently recommend and
provides a net benefit to our children at a cost
that we have already deemed acceptable.
References
References noted in this article are avail-
able from the authors or the editors of Iowa
Medicine. EO
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Iowa Medicine Volume 85 / 5 May, 1995 211
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Iowal Medicine THE EDITOR COMMENTS
Why are so many
people depressed?
If there be a hell upon earth it is to be
found in a melancholy man’s heart.
Robert Burton (1577-1640), Anatomy of Melancholy
Over 11 million Americans suffer depres-
sion (major depressive disorder) each
year. Depression affects twice as many
women as men. It is known that depression is
not caused by any single factor. The exact
etiology is not known, but involves biological,
genetic, pychological and various life stresses.
Why are so many people depressed? We must
not be confused by depressed or sad moods that
are normal responses to specific life experi-
ences involving loss or disappointment. The
major depressive disorder involves far more
complex factors. Further, it is necessary to
differentiate unipolar and bipolar
mood disorders.
Nearly one in eight people may
require treatment for depression
during their lifetime. The direct
costs in the U.S. for treatment com-
bined with indirect costs from lost
productivity amounts to about $ 16
billion per year in 1980 dollars.
Yet, in spite of these startling
figures, experts contend depression is
underdiagnosed and undertreated by primary
care and other non-psychiatric practitioners.
And, these care providers are the ones more
likely to see these patients initially.
The Iowa Department of Human Services
processed 208,165 Medicaid claims for antide-
pressants during the period November 1, 1993
through October 31, 1994. These claims
Were the lack
of comforts
less stressful
than our world
of complex
technology?
amounted to over $6.5 million. Prozac® ac-
counted for 29, 526 claims totalling $2, 142, 102.
Other antidepressant drugs accounted for the
over 208,000 prescriptions. Antidepressants
were second only to cardiac drugs, and Prozac®
second to Zantac®.
Comparison of these statistics to general
prescribing patterns of antidepressants in Iowa
and the U.S. we can assume the cash is enor-
mous. It is striking also, that Zantac® is the
most frequently prescribed medication in these
reports (49,561 claims paid accounting for cost
of $2,710,192). Depression and ulcers. Which
comes first? Why are so many persons affected
by these two conditions? We hear the term
“stressed out” so frequently. Are these patients
facing such insurmountable crises that they
must be sustained with such phar-
maceutical agents?
The population of the U.S. is in
a sorry state when measured by
the prescribing of these two drugs.
Is our social status so precarious
or have we as mortal beings be-
come unable to cope with the
normal routines of our existence?
Is the world so tumultuous? Were the lack of
comforts and the fear of prehistoric monsters
less stressful than our world of electronics and
complex technology? We can only speculate
on these questions. Furthermore I shall not
delve into questions on whether antidepres-
sant drugs are injudiciously or over prescribed.
That question merits broad discussion and
consideration. [Ml
Marion Alberts, MD
Iowa Medicine Volume 85 / 5 May 1995 213
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Iowal Medicine
Reading fast . . .
now . . . slow
I used to be a fast reader. Or I thought so,
anyway, and the idea was occasionally rein-
forced by comments from friends. That was
before I started medical school. My slowness in
matching the words in Gray’s Anatomy with
the drawings, and correlating both with the
actual cadaver took its toll on speed. My physi-
ology text with its complex ideas, hypotheses
and murky prose added further deadweight.
Then came biochemistry and its lethal defini-
tions, equations and formulations.
Before the end of my freshman year I real-
ized my reading speed lay severely wounded,
almost moribund. Even newspaper articles and
the comic strip balloons seemed in shock. I felt
my eyeballs shifting a syllable at a time and I
sensed that my lips moved, too. Being an opti-
mist back then, I assumed these
injuries would soon heal and I’d
shortly be back to full vigor.
But soon came pathology, mi-
crobiology, internal medicine, sur-
gery and then the calamitous flood
of print in the form of journal ar-
ticles and excerpts. Occasionally,
with a magazine article or a “light”
short story or novel, I’ve had a prickles-on-the-
neck feeling of flickering improvement. If real
help was to arrive, it would need a long conva-
lescence and careful guidance from reading
therapists. No rescue has yet occurred.
I suspect I’ve lots of company in that sad
sequence and I feel better imagining an army of
fellow sufferers. If there be such, and any are
reading this confessional, maybe they (you)
might feel slightly soothed to learn the secret
shame is shared. And there’s still another rea-
son.
Part of the blame, I feel, for my lamentable
situation must lie with the vast numbers of
authors I’ve read. One can’t whip through
Shakespeare, of course, since Elizabethan En-
glish is so different from modern English or
modern American. If I’d stuck with Dickens,
Hemingway, Arthur Conan Doyle and Earl
Stanley Gardner, I’d probably have little to
lament. But no, I’ve read many more authors,
and regrettably, most of them produce that
misnomer called the biomedical and/or scien-
tific “literature”. Another factor has blighted
me, perhaps not you: I’ve needed in my work
not only to read but to try to correct or improve
a huge number of written items —
all sorts of reports, applications,
memos, students’ papers, items for
publication, and so on — some of
them, yes, my own. How all that re-
writing and copy editing slows one’s
reading! A wise man once said,
“When something can be read with-
out effort, great effort has gone into
its writing.”
I fear I’m incurable. But in a pitiable effort to
light the proverbial match in the darkness, I try,
here and there, to improve the quality of others’
writing as well as my own. If all that I read were
better written, maybe I’d improve, slightly. In
any case, I seem hooked on continuing to read;
even though slow, my reading of any kind still
seems inescapable and brings great joy. DU
I felt my
eyeballs shifting
a syllable at
a time and I
sensed that my
lips moved, too.
R T OF MEDICINE
Richard Caplan , Ml)
Iowa Medicine Volume 85/5 May 1 995 215
Iowa [Medicine
Classified Advertising
Mankato Clinic, Ltd. — A progressive group
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Family Practitioner — McFarland Clinic is
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Seeking quality physicians interested in
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Madison, Wisconsin — Dean Medical Center, a
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An Equal Oportunity Employer.
Janesville, Wisconsin — Dean Medical Center,
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216 Iowa Medicine Volume 85/5 May 1 995
CLASSIFIED ADVERTISING
LeMars , Iowa
Seeking quality physicians to prac-
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Janesville, Wisconsin — Dean Medical Center,
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Janesville, population 55,000, is a beautiful,
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Janesville, Wisconsin, Urgent Care —
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physician assistants on staff. Each physician
is at the clinic 6 hours a day, 4 days per week,
seeing between 20-25 patients daily. A
minimum $110,000 guaranteed salary plus
incentive is provided. For more information
please contact Scott M. Lindblom, Medical
Staff Recruiter, Dean Medical Center, 1808
West Beltline Highway, 1/800-279-9966, 608/
259-5151, fax 608/259-5294 or at home 608/
833-7985.
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
of Des Moines. We have a beautiful new
facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
Family Practice Opportunity
Perry Memorial Hospital
Princeton, Illinois
BC/BE family practitioner needed immed-
iately for full practice in this friendly
community. Practice includes:
• Competitive salary and benefit package
• Call schedule of 1:4
• 35,688 person draw area
• Affiliation with 98-bed, JCAHO accred-
ited Perry Memorial Hospital.
Princeton, Illinois offers high quality
schools and a safe environment in which to
live and work, as well as various cultural
and recreational activities. Contact:
Marie Noeth at 800/438-3745
or fax your CV to 309/685-2574.
Madison, Wisconsin, Urgent Care — Dean
Medical Center a 300+ physician
multispecialty group is seeking full time
physician to assist in staffing our two urgent
care centers. Qualified applicants should be
BE/BC in family practice, emergency medicine
or internal medicine with experience in
pediatrics. Dean Medical Center operates two
Urgent Care Centers 365 days per year, from
7:00 a.m. -10:00 p.m. All physicians employed
at the urgent care centers are paid on an
hourly basis and full time physicians are
eligible to go on a shareholder track and buy
into the corporation after two years of
employment. Excellent compensation and
benefits with shareholder eligibility after two
years of employment. For more information
contact Scott M. Lindblom, Dean Medical
Center, 1808 W. Beltline Highway, PO Box
9328, Madison, Wisconsin 53715-0328, at
work 1/800-279-9966 or 608/259-5151 or
home 608/833-7985.
Advertising Rates and Data
Regular classified advertising sells for $2.00
per line with a $30 minimum per insertion.
For members of the Iowa Medical Society
the rate is $20 per insertion. Display
classified advertising sells for $25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85/5 May 1 995 217
Iowa [Medicine
CLASSIFIED ADVERT I S I N
Orange City, Iowa
Exceptional opportunity for full-
time family practice physician to
join an 8-provider family prac-
tice clinic. Fully integrated with
hospital via employment contract
with excellent benefit package.
Hospital, clinic and long-term
care facility remodeled in 1993.
Family oriented Dutch commu-
nity of 5,000 located 90 miles
from Iowa Great Lakes. Excel-
lent public and parochial school
systems and liberal arts college.
Orange City Hospital and Clinic
400 Central Avenue NW
Orange City, Iowa 51041
712/737-5270
LA CROSSE
WISCONSIN
• Live in beautiful Mississippi River Valley.
• Work with high quality colleagues in
growing multispecialty group (70 physicians).
• Competitive income/benefits.
SPECIALISTS NEEDED
Cardiology
Critical Care/Pulmonary Medicine
Dermatology
Emergency Medicine
Family Practice
Internal Medicine
Neurology
Occupational Medicine
Orthopedic Surgery
Pediatrics
Urgent Care
Urology
Send CV to: P. Stephen Shultz, M.D.
SKEMP CLINIC
800 West Avenue South
La Crosse, Wisconsin 54601
Fax 608/791-9898 or
Phone 608/791-9844, ext. 6329
AN ARMY SCHOLARSHIP COULD
The U.S. Army Health Professions
Scholarship Program offers a unique
opportunity for financial support to med-
ical or osteopathy students. Financial
support includes tuition, books, and
other expenses required in a particular
course.
For information concerning eligibil-
ity, pay, service obligation and application
procedure, contact the Army Medical
Department Personnel Counselor:
CALL CPT. RHONDA HOWARD
1-800-347-2633
ARMY MEDICINE. BE ALL YOU CAN BE
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
Iowa[Medicine
Professional Listing
Allergy
Emergency Medicine
John A. Caffrey, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljko K. Zivkovich, MI)
Robert A. Colman, MI)
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Robert J. Harry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Bligard, MI), FAAD
James D. Hunker, MD, FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Hragc, MI)
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gervich, MD
Daniel J. Schrocdcr, MD
Ravi K. Vemuri, MI)
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
TVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Internal Medicine
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AO HIM
General Internal Medicine
William C. Robb, MD
Richard H. Brandt, MD, ABIM
Grace Z. Aug, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, Ml)
Laurence S. Krain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgcse, MD
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Ilosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
220 Iowa Medicine Volume 85/5 May 1 995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Hayne, Ml)
Thomas A. Carlstrom, Ml)
David J. Boarini, MI)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, Ml)
S. Randy Winston, MD
Douglas R. Koontz, MD
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad 1). Abcrnathcv, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-462 2
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, \ll)
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, MD
John M. Gracthcr, MI)
Gilbert W. Harris, MD
James A, Davison, MI)
Norman F. Woodlief, MI)
Eric W. Bligard, MI)
David D. Saggau, MD
Steven C. Johnson, Ml)
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert 1). Whincrv, MD
Stephen H. Wollten, MD
Robert B. Goffstein, MD
Lyse S. Strnad, MD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MI)
Bradley L. Isaak, MI)
Randall S. Brcnton, MD
James L. Dummett, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51 101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Iowa Orthopaedic Center, PC
Marvin II. Dubansky, MD
Marshall Flapan, MD
Sinesio Misol, MD
Joshua D. Kimclinan, DO
Timothy G. Kenney, MD
Lynn M. Lindaman, Ml)
Jeffrey M. Farber, MD
Kyle S. Galles, MD
Scott A. Meyer, MI)
Cassim M. I gram. Ml)
Donna J. Bahls, MI)
Jill K. Mcilahn, DO
Jacqueline M. Stoken, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Otolaryngology
Iowa ENT, PC
Thomas A. Ericson, MD
Marshall C. Grciman, MI)
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Hill, MI)
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: ,S 10.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85 / 5 May 1995 221
Iowa (Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MD
Eugene Peterson, MD
Richard B. Merrick, MI)
Peter V. Boesen, MD
Robert R. Updegraff, MD
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolarvngologv-Hcad & Neck
Surgery, PC
Thomas J. Benda, Sr., MD
James W. White, MD
Craig C. Herther, MD
Thomas J. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MD
Guy E. McFarland, MD
Thomas F. Viner, MD
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose arid Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Perinatology
Des Moines Perinatal Center, PC
Neil T. Mandsager, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, Ml)
Steven G. Berry, MD
Donald L. Burrows, MI)
Michael Witte, DO
Gerard A. Matysik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary Diseases
Surgery
Wendell Downing, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice I). Schncll, MI)
Farccduddin Ahmed, Ml)
Arthur B. Searlc, MD
Bogdan E. Krvsztofiak, Ml)
Rehabilitation Medicine Associates
William I). dcGravellcs, Jr., MD
Charles F. Dcnhart, MD
Marvin M. Hurd, MD
William C. Koenig, Jr., Ml)
Karen Kicnkcr, Ml)
Todd C. Troll, MD
Lori A. Sapp, MD
Younker Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Advertising Index
Beniie Lowe & Associates 223
Blue Cross Blue Shield 219
Dale Clark Prosthetics 214
Hawkeye Medical Supply 193
IMGMA 190
IMS Sendees 186
Josephs 212
Medical Protective Company 208
Medical Records
Assistance Sendees 207
MMIC 224
Monroe Clinic 207
Skemp Clinic 218
U.S. Air Force 199
U.S. Army 218 j
LT.S. Army Resen e 211
222 Iowa Medicine Volume 85/ 5 May 1995
Iowa [Medicine
THE PRESIDENT COMMENTS
Why we need to
organize
This is my first column as your IMS presi-
dent and I’d like to use this opportunity
each month to keep in touch with you on
the issues I find most relevant to the practice of
medicine today.
Although the obvious pressure for health
system reform in Washington is less evident,
limited health system reform remains alive in
Congress and will undoubtedly occur. Reform
is occurring in the private sector at an unprec-
edented rate. While no one knows exactly what
these changes will bring, there are some things
which are evident such as the formation of
hospital networks or systems like the Iowa
Healthcare System which involves hospitals in
Des Moines and Cedar Rapids plus various
smaller outlying hospitals.
Physicians also must organize,
though this is not news to any-
body. For the past few years, the
IMS has promoted education in
how to form physician organiza-
tions. Physicians have been
encouraged to form POs so they
may better deal with their local
hospital and the emerging major
networks.
One of the problems we face when POs are
established is surrender of autonomy. When
you organize, you give up some of your au-
:onomy. It also means trusting your colleagues,
dhoose good people and then let them do their
ob.
Another factor which is a real change for
nost physicians relates to the assumption of
financial risk in the various health care pro-
vider organizations. As in all spheres of
economics, risk is related to return. We as
physicians should be willing, through our orga-
nizations, to assume risk.
Another very good reason for physicians to
be organized is the potential for an abrupt
change in patient referral and care patterns
that can occur with managed care. Instead of a
slow trickle of patients going to another health
care source, the change comes about much
more dramatically. Iowa may be a little differ-
ent because of our large number of rural
physicians and rural population. However, 80%
of Iowa doctors are in 16 counties. Those that
are in rural areas may have a factor of insula-
tion those in larger cities do not enjoy.
In the future, POs may be affili-
ated with various health care
delivery systems and the IMS will
become a logical way for these
physicians to advocate patients
when problems arise. The IMS has
always assumed this role but the
degree of involvement could be-
come greater.
This year will see the continued evolution of
POs and health care delivery systems and inter-
facing of these organizations and networks.
There will be other important issues such as
CHMIS and the IMS campaign against violence.
I encourage you to be involved so you can
influence your fate and the fate of medicine.
Above all, we must always make sure patient
care is our number one primary concern. O
Physicians
should
be willing,
through our
organizations,
to assume risk.
Joseph K\ll, MD
Iowa Medicine Vahitii£j$5JJL-Jim£jJ225. 231
Iowa I Medicine
IMS Update
AT A GLANCE
The American Medical
Association has begun
the process to select a
successor for James
Todd, MD, who announ-
ced he is retiring as AMA
executive vice president
in June, 1996. Five AMA
board members have
been appointed to a
search committee. They
are: Frank Walker, MD of
Michigan (chair); Yank
Coble, Jr., MD, Florida;
Richard Corlin, MD,
California; Nancy Dickey,
MD, Texas; Robert McAfee,
MD, AMA president.
•
David Bickham, execu-
tive director of the
Oklahoma Medical Assoc-
iation, has sent a special
message to everyone in
the organized medicine
federation who contact-
ed the OMA regarding
the bombing in Okla-
homa City. “The outpour-
ing of support from our
members was astonish-
ing and gratifying, ” Bick-
ham said. “Many physi-
cians closed their offices
and reported to hospital
emergency rooms in the
proximity of the disas-
ter. ”
IMS elects physician officers
Joseph Hall, MD, a Des Moines radiologist,
was installed as president of the Iowa Medical
Society on Sunday, April 30. The installation
ceremony concluded the Society’s three-day
House of Delegates and Scientific Session at
the Marriott Hotel.
Other physicians elected to office are:
President-elect (1-year term) — William
McMillan, MD, Ottumwa.
Vice-president (1-year term) — Sterling
Laaveg, MD, Mason City.
Trustee (3-year term) — Siroos Shirazi,
MD, Iowa City.
Speaker, House of Delegates (1-year term) —
Donald Kahle, MD, Dubuque.
Vice speaker, House of Delegates (1-year
term) — Tom Throckmorton, MD, Spencer.
AMA delegates (2-year terms) — Clarkson
Kelly, Jr., MD, Charles City; Daniel
Youngblade, MD, Sioux City.
AMA alternate delegates (2-year terms) —
Bernard Fallon, MD, Iowa City; Bryan
Pechous, MD, Dubuque.
Councilor, District I — Robert Kent, MD,
Burlington; District VI — John Justin, MD,
Mason City; District IX — Jay Heitzman,
MD, Ottumwa; District XIII — Linda Iler,
MD, Lake City.
In addition, Harold Miller, MD, Davenport,
was elected chairman of the IMS Board of
Trustees and John Brinkman, MD of Mason
City was elected secretary-treasurer.
More about the president-elect
William McMillan, MD, an Ottumwa oto-
laryngologist, was elected president-elect of
the Iowa Medical Society on Sunday, April
30. Dr. McMillan graduated from the
University of Michigan Medical School and
served a residency at the University of Iowa.
He has served on numerous IMS commit-
tees and as a delegate. He will take office in
April of 1996.
IMS domestic violence video complete
The Iowa Medical Society’s videotape
“Break the Silence; Begin the Cure” on
domestic violence is complete and available
for loan to any Iowa physician. The videotape
is 27 minutes long, contains Iowa experts and
is aimed at educating Iowa physicians on how
to manage victims of domestic abuse. The
tape was a project of the IMS Task Force on
Domestic Violence.
Any physician wishing to borrow the
videotape should call Chris McMahon, IMS
director of communications, at 515/223-1401
or 800/747-3070. The tape can also be pur-
chased for 820.
Specialty' Society7 Update
Nearly 300 clinic managers and 120 exhibitors
attended the IMGMA Spring Meeting May 3-5 at the
Des Moines Marriott. This was the largest meeting
ever held by IMGMA.
Dr. Jeffrey Watters is the newly-elected president of
the Iowa Academy of Otolaryngology. Dr. Martin
Shularik is president-elect and Dr. Timothy Grissom is
secretary-treasurer.
Twenty-three physicians attended a recent meeting of
the American Medical Directors Association, Iowa
Chapter. Dr. Robert Bender and Dr. Stanley Haugland
gave presentations on managing acutely ill patients in
nursing homes and quality of life for the elderly.
Over 75 anesthesiologists attended the Iowa Society
of Anesthesiology Anesthesia Update meeting in early
April in Des Moines. Dr. Norig Ellison, president-elect
of the American Society of Anesthesiologists, was the
guest luncheon speaker.
Members of the Iowa Association of County Medical
Examiners discussed DCI lab usage at a recent meet-
ing held at IMS headquarters.
The transition to Medco Behavioral Health operating
the Medicaid mental health benefit for the state of
Iowa continues to cause concern for Iowa psychia-
trists. The time necessary to obtain approvals for in-
patient services has caused delays and contracts sent
to Iowa psychiatrists have been problem areas. The
Iowa Psychiatric Society has appointed a Medco Task
Force which meets about every two weeks.
232 fmoin. MpAirinp
Vn1.ii.mp 55 / 6 Jn.ru>. 1 905
CURRENT ISSUES
Focus on IMS Alliance
A recent survey indicated the top concern for the
Alliance is membership growth and retention. The AMA
Alliance has developed a plan to promote Family
Violence Prevention as our first national health promo-
tion project. All counties and states are urged to par-
ticipate in SAVE: Stop America’s Violence Everywhere.
A SAVE violence-free day will be held on October
11, 1995. We will hear more about this program dur-
ing our IMSA Summer Board meeting July 19-20 in
West Des Moines.
The joint IMS/IMSA mini-intemship program is
again one of our priorities. During the past five years,
over one-third of all Iowa legislators have participated
in this program. This year, we are expanding the pro-
gram to include congressional representatives.
Don’t forget that the AMA-ERF funds are more des-
perately needed than ever. As the federal government
decreases loans for students, we must pick up the
slack. Fifty percent of those who quit medical school
do so because of lack of funds.
I am pleased to serve as 1995-% IMSA president. I
urge all spouses to get involved and make a difference!
Contributed by Linda Miller, president, IMSA
IMS physician award winners
The 1995 IMS Merit Award was given to
Laverne Wintermeyer, MD, Des Moines,
Saturday evening, April 29 at the IMS Annual
Banquet at the Marriott Hotel.
Dr. Wintermeyer is the state epidemiolo-
gist and received the award for his work as an
effective liaison between Iowa physicians and
the Iowa Department of Public Health, from
which he retired last October. He has served
on an IMS Task Force on AIDS.
Dr. Herman Hein, Iowa City, received the
Ben T. Whitaker Award of the Interstate
Postgraduate Medical Association of North
America. Dr. Hein is a professor of pediatrics
at the University of Iowa College of Medicine
and is credited with starting the statewide
perinatal program in Iowa.
Dr. Paul Laube, surgeon from Dubuque,
received the Iowa Medical Society’s Physician
Community Service Award. Dr. Laube’s civic
activities include serving on the University of
Dubuque Board of Directors and Dubuque
Rotary Club. He has been director of the
Bethany Home, a local retirement center.
IMS honors lay individuals
The John H. Sanford Award was given to
Jim Koch, longtime executive secretary of
the Rock Island and Scott County Medical
Societies. Mr. Koch retired May 1 after 25
years of service to the medical profession.
This award honors lay individuals for contri-
butions to the medical profession.
Mary Ann Bechler, clinic administrator for
the Northwest Iowa Orthopaedic and Sports
Center in Sioux City received the IMS
Outstanding Office Administrator Award at
the IMS Annual Banquet Saturday evening,
April 29. Ms. Bechler works with four physi-
cians and 25 employees and has been active
in both professional and civic organizations
at the state and local levels.
Members of the IMS Alliance were recipi-
ents of the Washington Freeman Peck Award
for their contribution to the health care field
and for efforts in educating physicians and
the public about domestic violence.
Notice from Iowa BME
The Iowa Board of Medical Examiners
(BME) is recruiting Iowa physicians to serve
on its peer review committees. Licensed
physicians board certified in anesthesiology,
emergency medicine, internal medicine, fam-
ily practice, obstetrics/gynecology, surgery or
psychiatry are strongly urged to apply.
Peer review committees in each specialty
evaluate quality of care cases and report find-
ings and recommendations to the Board.
When conducting peer reviews for the Board,
committee members are under contract with
the state and, as such, are granted immunity
from civil liability under law. Peer reviewers
receive nominal payment for their services
and compensation for most expenses.
For additional information, on serving as a
peer reviewer, contact Ann Martino, execu-
tive director of the BME, at 515/281-5171.
New project to help stop teen pregnancy
Members of the newly-formed Mahaska
County Medical Society Alliance have
embarked on a new project to help stop
teenage pregnancy. The Alliance is raising
money for purchase of “Baby, Think it Over”
dolls to donate to area schools.
The dolls cry and do not stop until the doll
is picked up and a feeding plug inserted. The
Alliance hopes to purchase 10 of the dolls for
Oskaloosa High School. For more informa-
tion, call Karen Messamer, 515/673-5165. HO
Iowa [Medicine
Futures
AT A GLANCE
At its recent House of
Delegates, the Iowa
Hospital Association
decided to change its
name to Association of
Iowa Hospitals and
Health Systems. The
official name change
will occur sometime this
summer.
The Sacramento Medi-
cal Society is putting
heat on an HMO that
recently terminated 100
area specialists without
cause. The SMS placed
an open letter in the
local paper expressing
the opinion that the ter-
minations were done
without concern for
patients.
ABC News is preparing
a series of Tim Johnson
reports on managed
care issues. Dr. Nancy
Dickey, AMA trustee,
will be interviewed for
the series. As of press
time, air dates were not
yet determined.
Capitation: a physician’s guide
Later this summer, the AMA. will publish a
new book entitled Capitation: A Physician’s
Guide. The book is expected to be available
July 30.
The book is written to help physicians
understand what capitation is and how it may
affect your practice. To really prepare for cap-
itation, says the AMA, you need to learn
about it now. The book will help you evaluate
capitation agreements and rates and tell you
how to thrive under capitation.
For more information on purchasing the
book, call the AMA at 800/621-8336.
Emphasis on board certification
The requirement of board certification as
the primary qualification for a physician con-
tracting with managed care plans is growing.
A recent article in the Internist , a publication
of the American Society of Internal Medicine,
questions whether board certification should
be the only requirement considered.
“The public accepts certification as a reli-
able measure of quality, but both physicians
and health plans are asking, ‘Is this really a
valid measure?’,” writes Lee Newcomer, MD,
medical director of United Healthcare.
Though board certification is a worthy
measure of achievement, the article said,
other factors such as patient satisfaction, a
physician’s ethical nature and clinical judg-
ment should be considered.
Medicare battle heating up
Amid predictions that the Medicare fund
will go broke in less than 10 years, lawmakers
are struggling to find ways to curb spending
without incurring the wrath of groups such as
the American Association of Retired Persons.
The AMA and others have begun discussing
income-based premiums for well-off Medicare
recipients; AARP vows to fight any such pro-
234 Iowa Medicine Volume 85/6 June 1 995
posals and is calling for cuts in other parts of
the federal budget to fund Medicare.
President Clinton, in a speech at the White
House Conference on Aging, vowed to defend
Medicare against budget-cutting Republicans
in Congress. According to the AMA, the
Wliite House declined a GOP invitation to
propose ways to restructure Medicare.
Republican leaders in Congress say they’ll
defer proposals to restructure Medicare for at
least several months so the politically explo-
sive question of health care for the elderly
will not become entangled in Congressional
efforts to slash the federal budget deficit.
Both the President and Republicans are
apparently assuming that whoever first spec-
ifies cuts in Medicare will suffer severe politi-
cal damage, reports the AMA.
Patient rights, responsibilities
The National Health Council has endorsed
a statement listing patients’ rights and
responsibilities in the new health care envi-
ronment. The statement has been enthusias-
tically endorsed by the AMA:
All patients have the right to:
1. Informed consent in treatment decisions, timely
access to specialty care and confidentiality protections.
2. Concise and easily understood information about
their coverage.
3. Information on how coverage payment decisions
are made and how they can be fairly appealed.
4. Complete information about the costs of their
coverage and care.
5. A reasonable choice of providers and information
about provider options.
6. Information about provider incentives or restric-
tions that might influence practice patterns.
All patients have a responsibility to:
1. Live healthy lifestyles.
2. Become knowledgeable about their health plans.
3. Participate actively in decisions about their
health care.
4. Cooperate fully on mutually accepted courses of
treatment. D3
CURRENT ISSUES
C H M I S Update
As part of the Iowa Medical Society's ongoing effort to educate Iowa physicians about the
Community Health Management Information System (CHMIS), this CHMIS Update page will be a
regular feature in Iowa Medicine.
IMS CHMIS Committee
The Iowa Medical Society’s Ad Hoc
Committee on CHMIS held a lengthy meet-
ing on April 4 to discuss issues of patient
confidentiality, use of the CHMIS data
base, costs of operating the system and the
governance and mission of CHMIS.
The committee approved an IMS state-
ment of policy on CHMIS. (The policy
statement was subsequently approved by
the 1995 IMS House of Delegates and is
reprinted on pages 243 and 244 of this
Iowa Medicine.)
The committee asked the IMS Board of
Trustees to consider joining with the Iowa
Hospital Association or other partners to
become joint administrators of the CHMIS
data repository, recognizing that the
CHMIS Governing Board still has control
of the repository. The IMS Board is now
exploring the committee’s proposal.
CHMIS Governing Board
The CHMIS Governing Board met in
March and selected a consultant to work
with the Technical Advisory Committee to
develop a Request For Proposal (RFP) for
the data repository. The Board is expected
to release the RFP after its August meeting.
An updated report was given on the six
other Hartford-funded CHMIS projects
around the country. None are continuing
in the community-mission, consensus-dri-
ven process Iowa is following.
CHMIS ADVISORY COMMITTEE ACTIVITIES
(IMS staff are observers at all advisory
committee meetings and work groups.)
•Ethics and Confidentiality
This advisory committee continues to
develop broad guidelines for appropriate
users and uses of data in the CHMIS repos-
itory. They have drafted a statement
regarding educating the consumer public
on data collection through CHMIS.
•Education and Communication
This advisory committee is developing a
proposed “Questions and Answers”
brochure about CHMIS.
•Technical Advisory
This advisory committee has divided
into two work groups — one is focusing on
the RFP for the data repository and one on
the certification process for networks. The
RFP group is meeting with the consultant
to begin writing the RFP.
The network work group has recom-
mended using the criteria developed by
the Electronic Health Care Accreditation
Commission (EHNAC) as the framework
for Iowa network certification criteria.
They are making final modifications to
tighten the criteria.
•Data Advisory
This Advisory Committee has made a
recommendation regarding what data ele-
ments should be collected for the CHMIS
repository from the UB-92 forms, HCFA-
1500 forms and from payers. This includes
payment and charge data. The recom-
mended list of data elements has been for-
warded to the CHMIS Governing Board.
The committee has begun work on a
patient satisfaction tool for use in CHMIS
Phase 1, and pharmacy claim data elements
to be collected by the data repository.
•Quality Review
This committee continues to review def-
initions and protocols for collecting the
data elements proposed by the Data
Advisory Committee. Those elements —
without clear definition or with variety in
protocol — are being identified for clarifi-
cation and standardization.
Look on page 242 of this issue for
more information on CHMIS!
on your horizon July 1, 1996
YOUR representatives
on state CHMIS
committees:
CHMIS
Governing Board:
Dale Andringa, MD
Des Moines
515/241-4102
Beth Bruening, MD
Sioux City
712/233-1529
CHMIS advisory
committees:
Communications /
Education
Laine Dvorak, MD
Thomas Evans, MD
Data Advisory
William Bonney, MD
John Brinkman, MD
Ethics/Confidentiality
Charles Jons, MD
Quality Review
Elie Saikaly, MD
William Langley, MD
Technical Advisory'
Thomas Menzel, MD
Mark Purtle, MD
IMS CHMIS
Committee:
Terrence Briggs, MD (chair)
IMS staff:
Barb Heck
Ed Whitver
Iowa [Medicine
Legislative Affairs
AT A GLANCE
As of press time, and in
spite of the Senate vote
to kill the Kyi amend-
ment capping noneco-
nomic damages in med-
ical liability cases, the
issue is not dead.
Because the House
passed a bill which
includes a cap, the issue
remains alive for con-
ference committee dis-
cussion. hi last week’s
vote, Senator Charles
Grassley voted not to
kill the cap; Senator
Harkin voted to kill it.
All IMS member physi-
cians are urged to write
to Senator Grassley and
thank him for his vote.
•
The Virginia Legislature
has sent the governor a
bill that would give
physicians and patients
the right to request an
external review of a uti-
lization review deci-
sion.
Review of bills in Iowa Legislature
The legislature adjourned its 1995 session
on May 4. Following is a review of hills of
potential interest to Iowa physicians. There
are many more bills that were introduced
this year although most did not go anywhere.
For more information on these issues or on
issues not covered, please contact Becky
Roorda or Paul Bishop at the IMS.
Liability Reform
The IMS was successful in gaining passage
of a reduction in the statute of limitation for
minors by the Iowa House of
Representatives, receiving support from both
Republicans and Democrats. However, the
bill has not passed in the Senate and was
assigned to the traditionally unsupportive
Judiciary Committee. IIF 394 remains alive
for 1996. Physicians are encouraged to work
with local state senators over the summer
and fall to let them know how important it is
to you and your patients.
Any Willing Provider
Several versions of any willing provider
bills were introduced but were not success-
ful. A “direct access to chiropractors”
amendment was adopted by the Senate in
the last weeks of the session. The House
refused to adopt the Senate language in spite
of heavy lobbying by chiropractors. We
expect to see this issue again in 1996.
Definition of surgery — SF 348
The IMS bill establishing a definition of
surgery failed to meet critical legislative
deadlines and did not pass. It was approved
by the Senate Human Resources Committee
but was referred to the State Government
where it died for the year.
Uniform Anatomical Gift Act — SF 117
The IMS worked with the Iowa Statewide
Organ Procurement Organization, the Iowa
Hospital Association and the Iowa State Bar
Association to update and improve Iowa’s
organ donation laws. The new law makes sev-
eral changes including allowing teenagers to
sign a document of gift with the cosignature
of a parent and legally recognizing the check-
mark on our driver’s licenses as a document
of gift. The July issue of Iowa Medicine will
contain more detailed information.
Trauma System — SF 118
The IMS supported SF 118 establishing a
statewide trauma system to ensure that all
components of Iowa’s trauma system are
coordinated. The plan includes a system for
voluntary verification of trauma capabilities.
Many IMS member physicians were involved
in the development of the plan.
Volunteer Physician Program — HF 197
The program initiated by the Iowa Medical
Society to provide state indemnification for
physicians who provide free medical care to
needy Iowans will be expanded to include
nurses and physician assistants beginning
July 1. Physicians and other practitioners
must receive specific approval for such pro-
tection by the state. For an application pack-
et, contact Cheryl Christie, Volunteer
Physician Program, Iowa Department of
Public Health, Lucas State Office Building,
Des Moines, IA 50319.
Board of Medical Examiners Impaired
Physician Program — SF 346
The IMS supported a successful initiative
by the Board of Medical Examiners to provide
confidentiality protection for mentally or
physically impaired physicians who voluntar-
ily report themselves to the Board of Medical
Examiners. Physicians who self report and
agree to cooperate with the Board in a treat-
ment program will be protected from public
disclosure through the state’s peer review
confidentiality laws.
Drug Testing of Babies — SF 150
Laboratory tests to detect the presence of
236 Iowa Medicine Volume 85/6 June 1995
CURRENT ISSUES
illegal drugs in infants and children per-
formed under state child in need of assis-
tance laws will have to meet criteria to be
established by the Iowa Department of Public
Health, according to SF 150. The require-
ment is intended to ensure that drug tests are
accurate and the presence of drugs in the
child’s system is confirmed before the test
results are used to remove a child from the
parent’s home.
Medicaid
SF 462, the Medicaid appropriations bill,
expands the prior authorization program for
Medicaid to include brand name drugs for
which there is an “A” rated generic bioequiv-
alent (no prior authorization for use of the
generic) beginning September 1. It also pro-
vides detailed instructions for a study of the
cost effectiveness of the Medicaid prior
authorization program and eliminates prior
authorization for Clozaril.
However, the bill does not prevent the
Medicaid program from continuing to imple-
ment strict criteria for payment for Clozaril
(clozapine). Existing Medicaid criteria close-
ly follow the restrictions placed on use of the
drug by its manufacturer Sandoz Pharma-
ceuticals.
SF 462 also funds for a 5% increase in
reimbursement for obstetrical care. The bill
has been signed by the governor.
Medical Education
SF 266 contains funding for the statewide
family practice residency program at a level
of $1,990,327 for the fiscal year beginning
July 1, 1995. This compares to $1,779,326
for the current fiscal year.
SF 266 also appropriates $770,000 for the
University of Iowa’s primary care initiative
with $330,000 of that amount for the depart-
ment of family practice.
The bill also contains continued funding
for the forgivable loan program at the
University of Osteopathic Medicine and
Health Sciences. The bill establishes a new
chiropractic graduate student forgivable loan
program. Up to $1,100 in loans will be forgiv-
en per year for up to four years of practice in
Iowa after completion of training at an Iowa
chiropractic school and a residency.
Domestic Abuse
SF 367 relating to domestic abuse was
approved by both houses. The bill:
•requires the attorney general to develop
written procedure and policies to be followed
by prosecuting attorneys in domestic abuse
cases;
•gives the juvenile court jurisdiction over
juvenile batterers, requires juvenile batterers
to attend a treatment program and allows a
parent to file a domestic abuse complaint on
behalf of a minor child;
•allows the court to order the defendant to
pay plaintiffs attorneys fees and court costs
in domestic abuse cases;
•provides for enforcement of protective
orders issued in other states.
As of publication, this bill had not been
signed by the governor. E3
Other bills
Passed:
•Child death review teams — SF 208
•Child support: state license revocation
allowed for nonpayment — SF 149
• Commitment criteria — HF 337
•Drunk driving restrictions — SF 446
• Insurance - individual insurance reform
and state tax deduction — SF 84
• Mental health coverage - study of cost and
cost effectiveness — SF 347
•Podiatrists renamed “podiatric physicians”
— SF 152
• Sex offender registry — SF 93
•Sexually violent predators — SF 432
Not passed:
•Abortion: statistical reporting — HF 522
•Abortion: mandatory parental notification
— SF 13
•Autopsy: religious exemption — SF 354
•Helmet laws for both bicycles and
motorcycles
• Medical records: copying charge limits
— SF 258
•Nurse practitioners: mandatory direct
reimbursement
•Physician assistants: change in licensure
and supervision requirements, direct
reimbursement
•Tobacco: improvements in clean indoor air
act and restricting youth access to
tobacco products
AA^^J
7QOC
Iowa | Medicine
Medical Economics
CURRENT ISSUES
Important CUA bill introduced
AT A GLANCE
Eighty of America’s 126
medical schools are
addressing the issue of
cost containment in a
required course; 31
have an elective course.
Just one year ago, one
medical school had
such a course. US
Healthcare and Humana
are establishing sum-
mer programs for med-
ical students to gain
first-hand experience
with HMOs.
♦
Federal researchers
report nearly 14 million
Americans — 7% —
have a problem with
alcohol. The problem is
worse among men and
more common among
young people ages 18-
29. Young non-black
men were twice as like-
ly to have a drinking
problem as young black
men.
•
The emergence of dental
HMOs is rapidly chang-
ing the business of den-
tistry, Dow Jones News
reported recently.
A bill which would exempt from the
Clinical Laboratory Improvement Act (CLIA)
all physician office testing except for Pap
smears was introduced last month by Ways
and Means Chairman Bill Arthur (R-Texas).
Rep. Thomas Bliley (R-VA) has promised
the American College of Physicians he’ll hold
hearings on the legislation this summer. Rep.
Bliley’s Commerce Committee has jurisdic-
tion over CLIA.
The bill represents mutual efforts on the
part of the House, the Senate and the White
House to ease regulatory burdens on physi-
cians and laboratories. All three are working
with HCFA regarding regulatory reforms.
A second major focus of attention is physi-
cian paperwork, including the Stark “attesta-
tion forms” which require physicians to tell
HCFA what they own and where their “finan-
cial interests” are.
Watch the Medical Economics page in
future issues for updates on regulatory relief.
Investors eye Medicare market
Despite differences in reimbursements,
more HMOs are eyeing cash payouts in the
Medicare marketplace and may enter the
business in the next few years, Investors
Business Daily reported recently.
Currently, 157 of America’s approximately
560 HMOs offer a Medicare product.
Currently, HMOs are flocking to the counties
in Florida, New York and California where
Medicare normally pays an IIMO $500 to
$700 per patient each month.
Great disparities in rates still make it
financially unrealistic for some HMOs to
serve elderly in many regions.
Medical futility guidelines needed
There may be occasional misunderstand-
ings by some physicians on the concept and
application of medical futility rationale,
according to a recent article in JAMA.
The article is based on a recent study to
determine use of medical futility rationale in
Do Not Attempt Resuscitation (DNR) orders
for inpatients. The researchers found evi-
dence of misunderstandings in the applica-
tion of quantitative (low probability of suc-
cessful cardiopulmonary resuscitation) and
qualitative (poor quality of life if CPR were
successful) futility.
The researchers believe intervention with
less than a 5-10% chance of success is quan-
titatively futile therapy. A figure of less than
1% has been proposed.
The authors said application of qualitative
futility to DNR orders must be preceded by a
discussion of quality of life issues with the
patient or surrogate and that education about
medical futility must be incorporated into
medical schools, residencies and continuing
medical education programs.
In late April, the IMS House of Delegates
approved a resolution to encourage the AMA
Council on Ethical and Judicial Affairs to
continue reviewing ethical issues related to
appropriate care at the end of life.
Supreme Court ERISA ruling
A ruling by the US Supreme Court demon-
strates there is a limit to ERISA’s pre-emption
power. The court voted unanimously to
approve New York State’s practice of adding
surcharges onto hospital bills paid by com-
mercial insurers, HMOs and employee bene-
fit plans to raise revenue to offset the expense
of indigent care and effectively subsidize Blue
Cross Blue Shield.
While the case does not technically affect
self-insured plans, it leads the way for lower
courts to reach the conclusion that the sur-
charge imposed on self-insured payers would
not be pre-empted under ERISA.
Opponents of the practice argued that
ERISA prohibits states from passing laws that
affect employee benefit plans. H3
Iowa I Medicine
CURRENT ISSUES
Practice Management
DEA registration numbers
Physician Drug Enforcement Administra-
tion (DEA) numbers were the focus of two
resolutions passed by the Iowa Medical
Society House of Delegates at its 1995 House
of Delegates meeting.
The House resolved that the IMS oppose
the use of DEA registration numbers for any
purpose other than verification to the dis-
penser that the prescriber is authorized by
federal law to prescribe controlled sub-
stances.
The House also resolved that the IMS
encourage physicians to report any inappro-
priate requests for DEA numbers to the Iowa
Board of Pharmacy Examiners and educate
physicians on the reporting process.
These actions were the result of various
payers and care delivery systems seeking to
use DEA numbers as physician ID numbers.
IMS policy parallels AMA policy in the belief
that there are other appropriate numbers to
use to identify physicians and the DEA num-
ber should not be used for this purpose.
For more information, call Barb Heck at
the IMS, 515/223-1401 or 800/747-3070.
Directory of Practice Parameters
The AMA has released its Directory of
Practice Parameters, medicine’s most com-
prehensive index of parameters, clinical
guidelines and other patient management
strategies. The book includes a list of nearly
1800 practice parameters (including 400 new
listings) developed by 75 physician organiza-
tions and other groups. For more informa-
tion, call the AMA at 800/621-8335.
Part B newsletter available through IMS
The IMS has available Part B News, the
nation’s leading independent Medicare
newsletter, at a special discount for IMS
members. Through the IMS, you can save
8107 off the regular subscription price.
Part B News is packed with the latest
Medicare payment policy changes and dozens
of tested reimbursement tips and clean-claim
strategies. When you subscribe, you’ll also
receive a complimentary “Plain English
Guide to Medicare Part B Reimbursement”.
For more information on Part B News, call
Linda Tideback at the IMS, 515/223-1401 or
800/747-3070.
Phase-in for CPT E & M guidelines
Between May 1 and July 31, 1995, carriers
will begin a phase-in process to review
records documentation to support CPT E & M
code billing using the HCFA E & M documen-
tation guidelines. Beginning August 1, 1995,
E/M codes will no longer be excluded from
the Medicare medical review system. Carriers
will vary in their timetables for utilizing the
guidelines in reviewing E/M codes. 113
Practice Management Workshops for You
Quality in the Medical Office
Wed., Sept. 6 Sioux City
Wed., Sept. 20 IMS headquarters
Wed., Sept. 27 Burlington Medical Center
This course examines trends in quality including
outcome measures and practice parameters.
For more information or to register for any IMS prac-
tice management workshop, call Mary Reinsmoen or
Sherry Johnson at IMS Services, 515/223-2816 or
800/728-5398.
Coding Seminars June 13 and 14
(All sessions at Best Western, Des Moines International)
Pediatric, Primary Care Coding June 13
Surgery Coding June 14
Taught by Nancy Maguire, director of education
and dean of the American Academy of Procedural
Coders.
AT A GLANCE
As managed care moves
into Iowa, physicians
are being asked to sign
contracts under which
they will provide care.
Many physicians have
little experience with
such contracts. The IMS
advises physicians to
consider this checklist
of contract pitfalls:
•Does the contract
contain a ‘hold harm-
less' clause which shifts
responsibility fo r liabili-
ty from the managed
care organization to the
physician?
•Does the contract
give you due process
rights upon termina-
tion?
•Does the contract
contain restrictions
such as non-compete
covenants?
•Does the contract
contain an ‘evergreen ’
clause which allows
automatic renewal?
Finally, never sign a
contract until you have
read it thoroughly and
understand it complete-
ly. You may wish to con-
sult an attorney.
Iowa [Medicine
CURRENT ISSUES
Practice Management
continued
Midwest Medical Insurance Company Focus on Risk Management
Jousting comments
Physicians and other health care profession-
als can inadvertently prompt a patient to file a
malpractice claim by making “jousting” com-
ments.
“Jousting” is arguing, belittling, criticizing
or complaining about another provider’s care
of the patient. Often, such comments are based
on incomplete knowledge of the facts sur-
rounding the initial care.
Plaintiff attorneys love to find evidence of
conflict among a patient’s health care profes-
sionals — it makes it easier to develop a case
against a physician.
Of course, inappropriate care should never be
covered up, but peer review or quality assurance
committees — not the medical record — are the
appropriate places to address disagreements
regarding judgement or treatment choices.
For further information, contact Lori Atkinson,
MMIC risk management coordinator, MMIC West
Des Moines office, PO Box 65790, West Des Moines,
50265, 800/798-9870 or 515/223-1482.
Physicians Help Caring Program Reach Uninsured Children
Janet is a smart and pretty 10-year-old who lives in
a small town in Iowa. Like other kids her age, she
likes to ride her bike, play sports and climb trees.
Her mom and dad are glad Janet is healthy and
active, but at the same time, they cannot help wishing
Janet would not play so hard. The company Janet’s dad
works for dropped health insurance coverage for em-
ployees and the family has not been able to find a policy
to replace it — at least not one the family can afford.
If Janet were to break an ankle, the hospital bills
could wipe out the family financially. Even a couple
visits to the doctor for a simple sprain or ear infection
can cost almost as much as a week’s worth of food.
So whenever Janet has a fever, her parents try not
to panic. They know they should take Janet to a
pediatrician for a checkup — it’s been a couple of
years since she had one — but they have no idea when
they will be able to afford it.
In Iowa, more than 25,000 children are growing up
without health insurance coverage. Most are chil-
dren of working parents whose income is too high for
Medicaid, but too low to afford health insurance or
routine medical care on their own. These are the
children physicians can refer to the Caring Program
for Children.
“These really are children at risk — at risk of getting
sick and not having the medical care they need to get
better and at risk of not getting the preventive care they
need to stay healty in the first place,” said Molly Kurtz,
administrator of the program. Created and administered
by the Caring Foundation, a non-profit affiliate of Blue
Cross and Blue Shield of Iowa, the Caring Program
currently provides health insurance benefits free of
charge for more than 2200 young-
sters statewide and has the ability to
cover even more.
Children enrolled in the Caring
Program receive basic health care
benefits, checkups and immuniza-
tions. These services are provided by
doctors who donate a portion of their
normal fees back to the program,
making it possible for the program to
stretch private funding to reach many
more children with the same dollars.
Over 100 Iowa hospitals and 2000
physicians participate in the program .
Physicians and hospitals refer un-
insured children to the program along
with school nurses and county DHS
offices. Enrollment kits can be made
available in your office or clinic. Call
515/245-4693 for more information.
Major contributors to the program include the State
of Iowa, Farm Bureau, Pioneer Ili-Bred International,
Norwest Bank and Proctor and Gamble.
240 frrtmn. Mprlininp. Volume 85 J_6 lime 7995
Iowa [Medicine
CURRENT ISSUES
Newsmakers
Awards, appointments, etc.
Forty-three Iowa physicians were accorded
Life Membership in the Iowa Medical Society at
the opening session of the Society’s House of
Delegates meeting Saturday, April 29 at the
Marriott Hotel. They are: Robert Allen, MD,
Burlington; William Baird, MD, Ames; Elmer
Bean, MD, Council Bluffs; James Coffey, MD,
Emmetsburg; Eugene Coffman, MD, Bellevue;
Russell Colliding, MD, Cedar Rapids; Dean
Cooper, MD, Fort Dodge; Thomas Coriden,
MD, Sioux City; Riehard Corton, MD, Water-
loo; Robert Donlin, MD, Harlan; Harley Feldiek,
MD, Iowa City; Frederick Fuerste, MD,
Dubuque; Louis Greco, MD, Boone; Charles
Gutenkauf, MD, Des Moines; John Huey, MD,
Cedar Rapids; Robert Jongewaard, MD, Wesley;
James Kennedy, MD, Coralville; Walter Kopsa,
MD, Tipton; Otto Kruse, MD, Tipton; Rufus
Kruse, MD, Marshalltown; Jean Le Poidevin,
MD, Waterloo; Edward Mason, MD, Iowa City;
Emmett Mathiasen, MD, Council Bluffs; Roger
Mattice, MD, Emmetsburg; Theodore Mazur,
MD, Burlington; Richard Miller, MD, Water-
loo; Robert Morrison, MD, Waterloo; Jack
Moyers, MD, Iowa City; Gerald Nemmers, MD,
Washington; Don Newland, MD, Des Moines;
Loran Parker, MD, Des Moines; Gordon Rahn,
MD, Mt. Vernon; John Singer, MD, Iowa City;
Glenn Skallerup, MD, Red Oak; William Spen-
cer, MD, Osage; Warren Swayze, MD.
Muscatine; Joel Teigland, MD, Des Moines;
John Thomsen, MD, Armstrong; Russell Van
Wetzinga, MD, Bettendorf; Donald Wagner,
MD, Sioux City; Janet Wilcox, MD. Iowa City;
and Grey Woodman, MD, Clinton. Dr. Russell
Gerard, longtime Waterloo surgeon, has re-
tired after 53 years of medical practice. Dr.
Gerard now conducts Allen Memorial Hospital’s
largest fund-raising project — a complex named
the Russell S. Gerard II, MD Hall — which will
house Allen College, Allen Memorial Hospital
School of Nursing and Radiologic Technology
Education Program. Dr. Ronald Lauer, profes-
sor of pediatrics and preventive medicine, UI
College of Medicine, was the primary author of
a May 10, 1995 article in JAMA entitled “Chil-
dren benefit from moderately low-fat diets.”
Dr. J. David Henderson has begun practice at
Ottumwa Family Practice. Dr. Henderson re-
ceived his medical degree from Memorial
University of Newfoundland, Canada. Dr.
Charles Wadle. Des Moines, has been certified
by the American Board of Psychiatry and Neu-
rology in the Added Qualifications in Addiction
Psychiatry. Dr. Kendall Reed, Des Moines, has
been appointed by the American College of
Surgeons for a three-year term as cancer liai-
son physician for the Mercy Cancer Center
program. Dr. Charles Clark, professor of
orthopaedic surgery, UI College of Medicine,
has been elected to the board of directors of the
American Academy of Orthopaedic Surgeons.
Dr. Otmar Albrand, neurosurgeon, has begun
practice at Grandview Medical Center in
Dubuque. Dr. John Strauss, UI College of Medi-
cine professor and head of dermatology, has
been awarded the American Academy of Der-
matology Gold Medal, its highest honor. The
award recognizes Dr. Strauss’ contributions as
a clinician, educator and researcher in derma-
tology. Dr. John Wollner, Cedar Rapids
dermatologist, has received the first Cancer
Survivor Advocate of the Year Award, pre-
sented by the Linn County Unit of the American
Cancer Society. The award recognizes an out-
standing contribution of time and energy which
improves the lives of cancer survivors or pro-
motes cancer awareness, education, prevention
or care. Dr. Robert Wallace, professor of pre-
ventive medicine and environmental health,
UI College of Medicine, was selected as one of
six new members of the National Institute on
Aging’s National Advisory Council on Aging.
Deceased members
Arthur Austin, MD, 73, radiology, Hiwasse,
Arizona, died October 2
Michael Colin, MD, 43, nuclear medicine,
Des Moines, died January 11 [H
AT A G1ANCE
Allen Health Systems in
Waterloo plans to merge
with Iowa Health System
in Des Moines. Allen
Health Systems includes
Allen Memorial Hospital ,
a 240-bed medical center
serving an 1 1 -county
area of northeast Iowa.
With the merger, Iowa
Health System now has
1975 licensed beds.
•
Dr. David Coster, of Sur-
gical Associates of
Grinnell, has been se-
lected as Iowa’s top “Out-
standing Young Iowan”
by the state’s Jaycees. Dr.
Coster is director of
trauma service at Grin-
ned Regional Medical
Center and is credited
with establishing a mor-
bidity and mortality con-
ference, expanding sur-
gical services to include
general thoracic and vas-
cular surgery and ex-
panding the functions of
the hospital’s radiology
department. The Jaycees
cited him for his role in
making “major changes
... in the pre-hospital
care of patients, improv-
ing safety factors and re-
sponse times. ”
Iowa I Medicine
FEATURE A R T I C L E
IMS, Iowa physicians
The 1994 Iowa Legislature passed a law establishing the
Community Health Management Information System for
Iowa. The CHMIS will affect the practice of every Iowa
physician. As the details of Iowa s CHMIS are determined, it is
imperative for physicians to stay involved in the process.
Sterling Laaveg, MD
Dr. Laaveg is a member of
the Iowa Medical Society’s
Ad Hoc Committee on
CHMIS and newly-elected
IMS vice-president. He is
an orthopedic surgeon in
Mason City.
Editor’s note: The following is a report given to the
IMS House of Delegates April 29, 1995 by Sterling
Laaveg, MD, a member of the Iowa Medical Society’s Ad
Hoc Committee on CHMIS.
CHMIS, the Community Health Manage-
ment Information System, has become a key
issue for Iowa physicians and will affect the
practice of every physician in Iowa.
In the early 1990s, there was renewed
interest in health data, much of this fueled
by the proposed national health reform
initiatives. Iowa took the lead and began to
work for health reform at the state level, and
the need for a valid and widely accepted
health data base became obvious.
The Iowa Health Data Commission and
other interested parties began to study what
became known as CHMIS. At the direction of
IMS leadership, the IMS
participated in the planning and
discussion process. Although the
IMS did not initially favor
development of a state health data
base, it became clear that the
Iowa Legislature favored and had
enough support to pass the CHMIS
bill. Therefore, IMS officers felt it
was important for the IMS to
continue in the planning process to influence
the development of the CHMIS. The IMS was
successful in amending the original
legislation to provide for implementation on
a phased-in basis, with electronic claims
transmission the focus of Phase I.
Governing Board oversees CHMIS
In 1994, the Governor signed CHMIS into
law. The bill provides for establishment of an
integrated electronic health management
information system for transmitting
information for health claim processing. The
bill also provides for a data storage repository
to give patients, physicians, hospitals and
others information on which to base
decisions on quality and effectiveness of care.
The law provides for a 12-
person Governing Board consist-
ing of two physicians, two hospital
representatives, two payer repres-
entatives and six consumer repres-
entatives who have authority for
implementing the CHMIS. The
state insurance division will
enforce the CHMIS law.
continued on page 245
It became clear
the Iowa
Legislature favored
and had
enough support to
pass the
CHMIS bill.
242 Iowa Medicine Volume 85/6 June 1 995
FEATURE ARTICLE
Iowa Medical Society Statement of Policy on CHMIS
(Community Health Management Information System)
Adopted April 30, 1995
The Iowa Medical Society (IMS), on behalf of
physicians and patients, maintains an active
interest and continuing involvement in the Iowa
Community Health Management Information System
(CHMIS) initiative and its implementation. IMS
representatives meet regularly to follow
developments and influence process, procedure and
outcomes. The IMS CHMIS committee includes
physician members of the CHMIS Governing Board,
each of the five CHMIS advisory committees and
other IMS member physicians.
This Statement of Policy has been formulated to
reflect the IMS position on CHMIS and guide IMS
member involvement in CHMIS development.
1. Development and implementation of the Iowa
Community Health Management Information System
(CHMIS) must continue to be under the overall
direction of a broadly representative Governing
Board which includes physician representatives.
It is of critical importance that the IMS CHMIS
Committee and physician representatives on the
Advisory Committees provide physician input and
guidance in the decision-making process to achieve
the mission of the Iowa CHMIS as listed below:
•Reducing the cost, improving the efficiency,
and simplifying the processing of claims and
payment transactions;
•Providing an efficient system to share
information on appropriateness, efficiency, and
effectiveness of health care services to assist in the
improvement of the quality of the health care
system for lowans;
•Providing data for research; and
•Supplying information for educational purposes
to enhance the health status of lowans.
2. Priority attention must be given to assuring
confidentiality of patient data, physician-patient
information, physician-physician information and
other sensitive information. In addition, a method
must be developed to assure the maintenance of
security in transmitting and accessing data in the
CHMIS repository and handled through the CHMIS
networks.
A mechanism must be developed to ensure that
individuals and/or organizations do not breach
confidentiality; penalties must be enforced.
There is a need for specific, carefully reviewed
guidelines regarding which entities or individuals
will have access to part or all of the database, with
special attention to patient specific data and
physician specific data.
3. AH networks should be required to meet or
exceed Iowa CHMIS Network Criteria set by the
Governing Board.
Approval of criteria for certification of CHMIS
networks shall be through a public process with
opportunity for public comment.
Rules relating to certification of networks shall
provide a mechanism for receiving complaints and
for decertification of a network for failure to meet
approved criteria including confidentiality.
Certification criteria shall be based on objective
standards.
The IMS favors the certification of multiple
networks which meet approved criteria.
4. Expense and revenue sources for the Iowa
CHMIS must be clearly defined. Cost/revenue
analysis should be conducted on each phase of
continued
This IMS policy has
been formulated to
reflect the IMS
position on CHMIS
and guide IMS
involvement in
CHMIS
development.
Iowa Medicine Volume 85/6 June 1 995 243
Iowa I Medicine
FEATURE ARTICLE
continued
The costs to
implement, operate
and maintain the
Iowa CHMIS should
not be paid solely
by physicians and
other providers.
CHMIS by the Governing Board.
The IMS should do an internal review of any
cost/revenue analysis and if necessary build
models which would demonstrate the cost
variations which could be expected under CHMIS.
The Phase I analysis should be completed by
October, 1995.
The costs to implement, operate and maintain
the Iowa CHMIS should not be paid solely by
physicians and other providers.
Office costs to implement, operate and maintain
the Iowa CHMIS should remain the same or reduce
the claim filing costs for physicians and other
providers.
O. All data collection and analysis efforts in the
state should be coordinated through CHMIS to
minimize duplication and reduce costs. It is
believed that all future data reporting requirements
should come through CHMIS.
6. The IMS supports a phased-in approach to
implementation of the Iowa CHMIS. The following
policy should guide the IMS during each phase of
implementation.
PHASE I
Collection and Submission of Data
(Legislative requirement that this phase be
operational by July 1, 1996)
a. In order to gain efficiency in HCFA 1500
claims processing, a standard claim format (ANSI
format), remittance format and patient eligibility
format must be enforced for all payers. Strict limits
must be placed on requirements for supplemental
information.
b. All insurance claims data must be included in
the database. Any necessary waivers or other
requirements to accomplish this must be pursued.
c. Payment deadlines must be established to
assure prompt payment to physicians by payers.
d. Precertification and eligibility verification
information must be accessible through the system
at the time of service. If not available by July 1,
1996, Phase I should be delayed.
e. All providers, as defined in Iowa Code Chapter
144C (Senate File 2069), should implement Phase
I simultaneously or if not possible, Phase I should
be delayed.
PHASE II
Expanded Data Collection and Submission
(Legislation requires development of
definitions to submit to Iowa General
Assembly no later than January 1, 1999 for
implementation by July 1, 1999)
a. Further definitions of the data included in
Phase II is necessary. Phase II includes: clinical
data sets, laboratory tests, x-ray results, and
inpatient pharmacy codes; measures of functional
outcomes; provider activity records for those in and
not in organized delivery systems.
b. Submission of data should be in a standard
format (ANSI or similar national format).
PHASE III
Totally Automated Status
(Only implemented after Phase I and Phase
II upon approval of Iowa General
Assembly)
a. The IMS opposes the creation of a central
repository to collect, analyze and disseminate
information from patients' medical records.
b. Further physician study of the proposed
collection and transfer process is required before
support can be given to Phase III.
244 Inborn Xfprlioinp Vnhimp ft ft / ft .limp 199ft
FEATURE ARTICLE
continued from page 242
The CHMIS law speaks to the importance
of confidential transmission and storage of
data. The Governing Board is to establish
operating policies; the Insurance Division is
to adopt rules to ensure confidentiality of
information and access only to authorized
parties. The Governing Board has estab-
lished five advisory committees. The IMS
has two representatives on the Governing
Board and 10 members or staff on the
advisory committees.
What are physicians required to do?
Providers will be required to submit health
claims via electronic transmission beginning
July 1, 1996.
Payers will be required to accept a
standard electronic transmission claim
format for all claims activity. They will also
be required to transmit eligibility verification
and remittance advice electronically.
Certified transaction networks will be
approved to operate in the electronic
transmission environment.
CHMIS will be implemented in three phases.
The focus now is on Phase I, which requires
physicians to submit HCFA 1500 claim forms
electronically starting July 1, 1996.
As the CHMIS design evolves, it is clear
that there are two main issues of concern to
physicians in Phase I: 1) protecting the
confidentiality of patient-specific medical
information transmitted and stored in the
CHMIS environment; and 2) assuring that
the cost to implement, maintain and operate
the Iowa CHMIS does not increase the cost
of claim filing for physicians.
It appears several aspects of the CHMIS
will be positive for physicians:
•Standardization of the claim filing form
and acceptance by all payers.
•Strict limits on supplemental information
required by payers to process claims.
•On-line electronic verification of patient
insurance eligibility.
•Electronic payment remittance advice
transmitted to physicians and the option of
electronic funds transfer if desired.
•An all-payer, all-patient data base used
for policy analysis and health research.
The IMS, through its committee and
representatives on five advisory committees
and the CHMIS Governing Board, has been
heavily involved in influencing the
interpretation and implementation of
CHMIS. Our goal is to provide leadership
that will assure the CHMIS is implemented
in a manner that will benefit physicians and
patients. In particular, our attention is
focused on confidentiality of patient-specific
medical information and upon who will bear
the cost of implementing the system.
IMS policy guiding physician involvement
We have developed a statement of policy
which we propose to guide IMS involvement
in CHMIS. There are still many, many
important issues to decide as CHMIS evolves
and is implemented in Iowa. Physician
members of the IMS will stay involved and
active in the five advisory committees and at
the Governing Board level. It is imperative
for all Iowa physicians to stay informed and
provide input to IMS leadership as we work
to influence the details of CHMIS
implementation in Iowa. (E3
Our goal is to
provide leadership
that will assure the
CHMIS is
implemented in a
manner that will
benefit physicians
and patients.
Iowa Medicine Volume 85 / 6 June 1995 245
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Iowa [Medicine
S C I E N C E AND EDUCATION
The Journal
of the 1 o w a Medical Society
Duodenal web with preduodenal portal vein
# Sergio Golombek, MD; Jagadish Bilgi, MD; Oneybuchi Ukabiala, MD
Congenital duodenal obstruction is an uncom-
mon but serious condition. Despite recent
improvements in surgical care of the neonate,
duodenal atresia continues to be associated
with a significant mortality rate. Prematurity,
associated anomalies, nutrition and marginal
pulmonary status present significant intraop-
erative and postoperative challenges.1 The sur-
vival rate of 72% in 1973 has increased dra-
matically due to improvement in neonatal
intensive care, rapid recognition and manage-
ment of other anomalies, increased use of
nutritional support and improved respiratory
therapy.2
Case report
A two-week-old white male born of a nor-
mal pregnancy by spontaneous vaginal deliv-
ery, was admitted to Raymond Blank Memorial
Hospital for Children with a history of projec-
tile vomiting since birth, two or three times
per day, either before or after feedings. The
vomitus was digested formula, sometimes tinted
with yellow. Fever and diarrhea were absent.
Physical examination revealed an alert,
afebrile “hungry-looking” white male with vigor-
ous cry, dry lips, “sticky” mouth and decreased
skin turgor. Vital signs on admission were within
normal limits. Body weight of 3.2 kg (25th per-
centile) was similar to the birth weight of 3.3
kg. The oral mucosa was moderately dry and
the soft, non-tender abdomen had neither pal-
pable masses nor visceromegalies. Although
peristalsis was not visible, positive bowel
sounds were present throughout.
With the assessment of vomiting and con-
comitant mild to moderate dehydration, the
patient was admitted to the pediatric ward and
started on intravenous fluids (maintenance
plus 7%). A real-time ultrasound scan of the
abdomen revealed neither a dilated nor an
elongated pylorus. Both stomach and duode-
num were filled with gas.
Due to the persistence of the symptoms in
the absence of positive findings, an upper gas-
trointestinal series was performed. Ten ml of
barium were injected through the nasogastric
tube followed by 40 ml of air. Barium flowed
rapidly through a fairly normal and almost
patulous pylorus and encountered a peculiar
structure in the proximal C-loop with further
distention of the proximal duodenum. An
obstructing membrane within the proximal C-
loop with a pin-hole opening distally was clear-
ly apparent (Figure 1). At no time during the
exam was gastroesophageal reflux observed.
Although very small quantities of barium
passed into the distal bowel, it was suspected
that the ligament of Treitz was normal in posi-
tion. In consultation with pediatric surgeons,
an exploratory laparotomy was performed.
The patient was found to have a Type I
duodenal atresia with a wind-sock duodenal
Figure 1. Obstructing membrane in the proximal C
loop. The outflow of barium from the proximal
duodenum is seen to occur through a very small
opening in the obstructed segment. Moderate
distention of the proximal duodenum is apparent.
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for June
1995.
Jagadish Bilgi, MD
Oneybuchi
Ukabl\u\, MD
Drs. Bilgi and Ukabiala
are associated with the
Raymond Blank
Memorial Hospital
Department of Pediatrics
in Des Moines.
Sergio
Golombek, MD
Dr. Golombek practices
at Children’s Mercy
Hospital in Kansas City.
Iowa I Medicine
Duodenal web with preduodenal portal vein
continued
—
Figure 2. Preduodenal portal vein (lifted by
hemostat). This vessel was located above the
proximal segment of the second part of the
duodenum.
membrane containing at its summit a hole
measuring about 0.5 cm in diameter. The dis-
tance from the membrane attachment on the
inside of the duodenal wall to its summit
measured about 2.5 cm. The common bile
duct ran within the posteromedial aspect of
the membrane to open on its inferior surface
about 0.5 cm proximal to its summit. There
also was a preduodenal portal vein overlying
the proximal portion of the second part of the
duodenum exactly over the operative field
(Figure 2). The stomach and the first portion
of the duodenum were hugely dilated and
hypertrophic. The duodenal web was excised
and a side-to-side duodenoduodenostomv
and appendectomy performed.
An upper gastrointestinal series four days
after surgery showed barium passing rapidly
through into the distal duodenum. Swelling
was seen along the lesser curvature or inferior
aspect of the duodenal sweep, presumably
post-surgical edema. The obstruction appeared
resolved and remnants of the duodenal web
were not apparent.
Recovery was excellent. He was treated
with ampicillin and tobramycin for three days.
After two days of total parenteral nutrition,
enteral feedings were started on the third post-
operative day. On the fourth day post-opera-
tivelv the patient was discharged.
Discussion
Most of the 19 infants with intrinsic duode-
nal obstruction in the study of Mooney et al
had Down’s syndrome and a number of other
associated anatomical anomalies including
ventricular septal defect, esophageal atresia
and tracheoesophageal fistula, dextrocardia
and other complex cardiac malformations.2 Of
the 49 patients with congenital duodenal
obstruction in the study of Akhtar and
Guiney, all but four had Down’s syndrome;
78% had other associated congenital anom-
alies, and, at surgery, three were found to
have the wind-sock anomaly, a variation of
the intact membrane (Type I atresia).3 The
membrane protrudes distally into the duode-
num and, consequently, the actual level of
obstruction may be several cm distal to the
point of the membrane origin.
Various operative techniques have been
used in the past for the treatment of congeni-
tal duodenal obstruction including duoden-
oduodenostomy and duodenojejunostomy
and excision or incision of the web3
Spigland et al reviewed 33 neonates who
underwent surgery for congenital intrinsic
duodenal obstruction.5 Bilious vomiting and
intestinal obstruction were the most frequent
symptoms. Ilydramnios and Down’s syndrome
were present in 75% and 21% of the cases,
respectively. Findings at laparotomy included
duodenal atresia (n = 14), annular pancreas (n
= 11) and duodenal diaphragm (n = 8).
The most frequent surgical procedure was
side-to-side duodenodudenostomy followed by
duodenojejunostomy and resection of web
with duodenoplasty. Bowel transit was reestab-
lished at a mean of 13.1 days (range 6 to 45
days). These investigators favored the partial
web excision with Ileineke-Mickulicz type
duodenoplasty for the treatment of intrinsic
duodenal webs when the proximal duodenal
pouch was not excessively dilated, because
bowel transit time was most rapidly restored
to normal when compared with other bypass
procedures.
In an attempt to reduce the risk of unex-
pected injury to the biliary tract during
surgery, preoperative endoscopy has been
routinely used since 1980 by Okamatsu et al,
who reported the first successful treatment of
congenital duodenal stenosis with endoscopic
membranectomy.6 Endoscopic membranec-
tomy can be performed with minimal surgical
complications. Bile flow for the papilla of
Vater should be confirmed prior to endoscop-
ic dissection of the diaphragm. Preoperative
evaluation for passage of the distal duodenum
using fluoroscopy, and the possibility of bal-
248 Iowa Medicine Volume 85/6 June 1 995
SCIENCE AND EDUCATION
loon catheter insertion through the opening
before dissection is also important for suc-
cessful endoscopic membranectomy.
According to Fernandes et al, only 63 cas-
es of preduodenal portal vein have been
reported in the literature.1 2 3 4 In general, this
rare anomaly occurs in children in associa-
tion with small bowel obstruction. Fernandes
et al described a newborn infant who, after
presenting with duodenal stenosis, mon-
golism and preduodenal portal vein, under-
went duodenoduodenal anastomosis without
mobilization of the portal vein.4 6
The embryogenesis of preduodenal portal
vein could be explained by the persistence of
a preduodenal vitelline communicating vein.
Sixty-four percent of patients with preduode-
nal portal vein are children. Two-thirds of
these cases are detected in the first week of
life due to associated intrinsic duodenal
anomaly, malrotation or Ladd’s bands. Anom-
alies associated with preduodenal portal vein
include annular pancreas, biliary atresia, pre-
duodenal common bile duct and cardiovascu-
lar malformations. The role of preduodenal
portal vein in the etiology of intestinal
obstruction is controversial. In 80% of
patients with preduodenal portal vein, an
intrinsic lesion of the duodenum or malrota-
tion is responsible for obstruction.7
The presence of preduodenal portal vein
complicates surgery for duodenal obstruc-
tion. While integrity of the vessel must be
preserved to avoid portal vein thrombosis,
the duodenum cannot be completely divided
and anastomosed anterior to the vein due to
the proximity of the pancreas and common
bile duct. Duodenoduodenal anastomosis is
currently the procedure of choice to treat this
anomaly. The anastomosis is created anterior
to the portal vein between the segments of the
duodenum immediately proximal and distal to
the obstruction. The portal vein will then lie
between the second portion of the duodenum
and the newly created anastomosis.
Summary
This article described an unusual case of
an infant with duodenal atresia and preduode-
nal portal vein without Down’s syndrome or
other anatomical anomalies associated with
this condition. Duodenoduodenostomy was
effective. Enteral feeding was re-established
72 hours post-operatively and the patient was
discharged home one day later.
References
1. Bailey, PV, et al: Congenital duodenal obstruction: a
32-year review. J Ped Surg 1993;28:92-5.
2. Mooney, D, et al: Newborn duodenal atresia: an
improving outlook. Am J Surg 1987;153:347-9.
3. Akhtar, J and Guiney, EJ: Congenital duodenal
obstruction. Br J Surg 1992;79:135-5.
4. Fernandes, ET, et al: Preduodenal portal vein:
surgery and radiographic appearance. J Ped Surg
1990;25:1270-2.
5. Spigland, N and Yazbeck, S: Complications associat-
ed with surgical treatment of congenital intrinsic duodenal
obstruction. J Ped Surg 1990; 1 127-30.
6. Okamatsu, T et al: Endoscopic membranectomy for
congenital duodenal stenosis in an infant. J Ped Surg
1989;367-8.
7. Escher, T: Preduodenal portal vein: a cause of
intestinal obstruction? J Ped Surg 1980;15:609-12. E]
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Iowa Medicine Volume 85/6 June 1 995 249
Iowa | Medicine
Service delivery to persons with HIV and AIDS
Edward Saunders, PhD
Susan Dolphin, MSW
Bery Engebretsen, AID
Saunders is an associate
professor, University of
Iowa School of Social
Work; Dolphin was
program coordinator and
Dr. Engebretsen is
executive director of
Primary Health Care,
Inc. at Broadlawns
Medical Center, Des
Moines.
# Edward Saunders, PhD, Susan Dolphin, MSW; Bery Engebretsen, MD
Given the magnitude of the AIDS epidemic,
an objective of Healthy People 2000 is to
increase by at least 80% the proportion of
HIV-infected people who have been tested for
HIV infection.1 In 1989, an estimated 15% of
approximately one million IIIV-infected peo-
ple had been tested at publicly funded clin-
ics; in 1991, nearly 2.1 million IllV-antibodv
tests were performed, compared with approx-
imately 79,000 tests in 1985. 2 Of those test-
ed in 1991, 57,879, or 2.8%, were HIV-posi-
tive.3
To promote expanded counseling and test-
ing of persons at risk, the U.S. Public Health
Service distributes funds authorized by the
Ryan White Comprehensive AIDS Resources
Act. Broadlawns Medical Center, Peoples
Community Health Clinic in Waterloo, Com-
munity Health Care, Inc. in Davenport, Polk
County Health Department, Black Hawk
County Health Department, Central Iowa
Chapter of the American Red Cross and
Cedar AIDS Support System were active col-
laborators in this project.
Service model
The program provided a total spectrum of
HIV-related services for the uninsured in
each of three major population areas of Iowa:
Des Moines, Waterloo and Davenport.
Through the Community Health Centers
(CHC) and affiliated agencies in each of these
areas, testing and counseling are available for
all persons at risk of HIV. In addition to
anonymous testing, each CHC assures the
provision of basic primary medical care for
HIV/AIDS patients. Each community has
active outreach and education programs tar-
geted at minorities, substance abuse, STD
and prison populations. By providing a coor-
dinated program, administrative costs have
been kept to a minimum and persons with
HIV and AIDS are provided the most humane
and cost-effective care.
Other services provided by the program
included immune status monitoring, the pro-
vision of AZT, Pneumocystis prophylaxis, cell
counts, chest x-rays, and certain TB tests;
plus coordination of speciality, mental health
and inpatient sendees. Costly duplication of
services is avoided and clients find an emo-
tionally-supportive resource. In addition to
health care, these needs may include: indi-
vidual, group or family counseling; legal aid;
housing assistance; financial assistance and
transportation. Case managers do office vis-
its, telephone contacts and home visits.
Findings from testing
In 1992, a total of 28,500 tests for HIV
(including 4,500 for the prison system) were
recorded by the University of Iowa Hygienec
Laboratory. Of these tests, 6,509 (23%) were
administered by sites in this program.
Although 7,535 persons sought testing at pro-
gram sites, only 6,509 tests were actually
administered. The remaining 1,026 persons
were counseled but not tested.
The four testing sites in this program were:
Broadlawns Medical Center, Polk County
Health Department, Black Hawk County
Health Department and Community Health
Care, Inc., Davenport. This is the first calen-
dar year for which data is available from
these testing sites. The Polk County Health
Department attracted the largest number of
persons seeking a test (4,937), followed by
the Black Hawk County Health Department
in Waterloo (1,241), Broadlawns Medical
Center (899), and Community Health Care
Inc., Davenport (457).
The average age of those who sought test-
250 Iowa Medicine Volume 85/6 June 1 995
SCIENCE AND EDUCATION
ing was 28.4 years. They were primarily low-
income, although 41% had private insurance.
The largest percentage of those seeking a test
(77%) identified heterosexual contact as the
probable route of exposure, followed by
homosexual-bisexual exposure (7%), and I.V.
drug use (3.5%).
Among the 6,509 tests administered, 37
persons were found to be positive for the HIV
virus. When the Enzyme-Linked
Immunosorbent Assay (ELISA) test, which
detects antibody to HTLV-III, was positive,
the Western Blot test was used to confirm the
positive findings. Fifty-six percent identified
homosexual contact as the source of the
infection; 36.1% identified heterosexual con-
tact; one person was homosexual with I.V.
drug use; and two had undetermined expo-
sure.
In 1992, 175 persons who were HIV posi-
tive or who had a diagnosis of AIDS were
served by the program.
The average age of program participants is
34 years; the majority are Caucasian (75.5%),
males (85.8%), whose primary route of infec-
tion is homosexual behavior (63.2%). Fifty-
five (31%) of the program participants have a
diagnosis of AIDS. (They are among the 108
new cases of AIDS reported in Iowa in 1992
and among the 425 cases reported since Feb-
ruary 3, 1983 when the first case of AIDS was
reported in Iowa.4)
Two women participants were pregnant in
1992. Sixteen program participants died in
1992 from diseases associated with AIDS.
Cost-effective care
A goal of the program was to provide
humane and cost-effective care. Nationwide,
it is forecast that the cost of treating all peo-
ple with HIV will increase 21% per year
between 1991 and 1994, and that $10.4 bil-
lion will be spent on treating all people with
HIV in 1994. The yearly cost of treating a
person with AIDS is estimated at $32,000;
and the yearly cost of treating an HIV-infect-
ed person without AIDS is $5,150.s Based on
cost data for 151 program participants in
Iowa, outpatient (publicly-financed) costs in
1992 for HIV+ and AIDS clients totalled
$247,538; an average of $1639 each. Inpa-
tient costs for 17 program participants in
1992 totalled $250,955; an average of
$14,762 each.
Combined costs for inpatient and outpa-
tient health care reached almost one-half
million dollars for approximately 150 per-
sons. This represents only a fraction of the
total expenditures for clients, since the cost
data is based on publicly-financed expendi-
tures and does not include mental health and
social support expenses. However, without
the management of these cases by profes-
sional social workers and nurses, the costs of
care might be expected to have been signifi-
cantly greater.
Conclusion
If the experiences of Iowa mirror those of
other sites nationwide, we can expect that
HIV-positive persons identified early through
testing will be better served and that individ-
uals who test negative will modify their risky
behavior as a result of the pretest and
posttest counseling. It is projected that high
risk populations — notably IV drug users,
minorities and the prison population — will be
better served in future years. Iowa has
accepted the challenge of the National Com-
mission on AIDS to “transform indifference
into action.”6
References
1. U.S. Department of Health and Human Services,
U.S. Public Health Service: Healthy People 2000: Nation-
al Health Promotion and Disease Prevention Objectives.
1990. Washington, D.G.
2. Current trends: publicly funded HIV counseling
and testing — United States, 1991. AIDS Weekly Septem-
ber 21, 1992:23.
3. Agency recommends increased HIV testing at pub-
lic health clinics. AIDS Weekly September 7, 1992:9.
4. Crist, L: Training for Iowa physicians: The latest in
AIDS education for health care professionals. Iowa Medi-
cine 1993;83:143-45.
5. Hellinger, F: Forecasting the medical care costs of
the HIV epidemic in the United States: 1991-1994. AIDS
Weekly July 22, 1991:20.
6. National Commission on AIDS. America Living
with AIDS. Washington, D.C.; 1991.
Note
This article was accepted for publication
in 1993 when this project was fully opera-
tional; it has since been modified. IE]
Iowa Medicine Volume 85/6 June 1 995 251
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-562-2218
Des Moines: 515-245-4688
Iowa [Medicine
THE EDITOR COMMENTS
Oath of Hippocrates
still valid
The Oath of Hippocrates has been consid-
ered the earliest and most impressive
document in medical ethics. Garrison in
his monumental History of Medicine declares
that Hippocrates was a product of the “classics
period” (460-136 BC), a time never before or
since that “so many men of genius appeared
within the narrow limits of space and time.”
Contemporaries of Hippocrates included
Sophocles, Euripides, Aristophanes, Socrates
and Plato. Now this Oath after over 2300 years
increasingly is being challenged; yes, even vio-
lated.
Perhaps there are medical graduates of re-
cent years who were not required to adhere to
the Oath or elected to reject it. For centuries
here and abroad, the recitation of
the Oath of Hippocrates was in-
cluded when the medical student
attained the title “physician”.
What has prompted a degree of
disclaim toward this time-honored
Oath? Is it disrespect for its pre-
cepts? Is it due to an emerging
social concept that freedoms of ac-
tion need not be tempered with
responsibility? It is a matter of greed for
compensation for what in the terms of the Oath
were considered a responsibility of one physi-
cian to all others? Or is this another inroad by
the legal profession?
The latest thrust at demeaning the concepts
of the Oath is seeking to hold patent rights on
procedures and techniques, e.g., a particular
method or operative incision, as was granted to
an Arizona surgeon who now seeks royalties to
be paid by any other surgeon who uses the
technique. Another patent has been issued for
a method of detecting certain kinds of tumors.
It has been time-honored that physicians shared
their skills and discoveries of procedure.
Our Iowa Congressman, surgeon Greg
Ganske, has introduced a bill (HR 1127) into
Congress to limit the issuance of patents on
medical procedures. More precisely the bill
prohibits the issuance of a patent of “any inven-
tion or discovery of a technique, method or
process for performing a surgical or medical
procedure; administering a surgical or medical
therapy; or making a medical diagnosis, except
if the technique, method or process is per-
formed by or is a necessary component of a
machine . . . which is itself patent-
able subject matter. ” Last year the
AMA House of Delegates took a
stand against medical and surgical
procedures patents, declaring them
unethical.
It is hoped Congress can under-
stand the Hippocratic Oath. Does
any other profession swear to an
oath that has withstood over 2300 years of trial
and testing? When I received my medical
degree, the recitation of the Oath was a serious
part of our graduation. How many of my col-
leagues can say the same? How many believe
the entire Oath to be antiquated and no longer
appropriate? DEI
Now this Oath
after over 2300
years increas-
ingly is being
challenged; yes,
even violated.
Marion Alberts, MD
Iowa Medicine. Volume RS / S June 199S .JtSSL
Happy
Anniversary
Rath!!
40 Years’
Service
To Iowa
Physicians! !
And, Goiny
Strong!!
In 1955 Ruth Clare’s name was brand new
to Iowa physicians.
That’s changed dramatically over 40 years.
Now, in 1995, Ruth’s name is well known to
Iowa Medical Society members and their
staffs.
We’re proud to salute Ruth on the fortieth
anniversary of her employment, first with
The Prouty Company, and now with its suc-
cessor, Bernie Lowe & Associates, Inc.
To many Iowa doctors and clinic managers,
Ruth is a cordial voice on the telephone or
a signature at the bottom of an informative
letter. On other occasions, she’s a pleasant
face across the table in your office or ours —
explaining how a particular IMS-sponsored
insurance program works.
Ruth continues to represent BLA ably. She’s
real life testimony to our commitment of
service to Iowa physicians.
Please join us in congratulating Ruth on her
long and excellent performance. She and all
of us at Bernie Lowe & Associates are proud
of our long association with the Iowa
Medical Society.
Call us when we can help with your per-
sonal insurance needs — or those of your
practice.
BERNIE LOWE & AS50EIATE5. INE.
Insurance Administrators to Professional Associations &
Universities and Colleges
515-BBB-BB11 I-BBB-94B-471B FAX 515-BBB-B915
B7BB Westown Parkway. Suite 41B
West Bes Moines. Iowa 5BBB6-1411
Iowa [Medicine
PHYSICIAN LEARNER
The advancement
of practice
The advancement of medical care is a
describable phenomenon in which the
practicing physician has an essential role.
That role, however, is not necessarily predict-
able.
Something happens on the way to the pro-
duction of a medical textbook. Deliberative
studies in the laboratory may result in recom-
mendations for the use of a drug or procedure.
If the recommendations are validated in con-
trolled clinical trials, a paper may be prepared
for the peer-reviewed literature. Other investi-
gations may duplicate the published findings
and subsequently the therapeutic innovation is
triumphed at professional meetings and in clini-
cal journals. Eventually, the widely accepted
treatment is incorporated into standard medi-
cal texts.
This progress of events is of
course only representative of the
many scenarios that translate new
knowledge into practice. The most
ignored pathway of change begins
with the inquisitive practitioner.
While elements of medical care
become routine in the practice of
the physician, the unexpected find- ■Bll,,,l,lllll,lll“
ing provides a challenge. The unusual symp-
tom, the difficult-to-describe rash, the unan-
ticipated improvement, the sudden deteriora-
tion— each of these patient developments
should provoke the practitioner to ask why has
this event happened. The medial texts, printed
or on-line, may not offer an answer.
What is the practitioner to do in this situa-
Something
happens on
the way to
the production
of a medical
textbook.
tion? Generally the consultation or advice of a
colleague is sought, to either confirm the obser-
vation or seek a plausible reason. We can read
about many examples of how this process has
been employed in the history of practice. There
are images of studious physicians making de-
tailed observations in bound notebooks. The
observations may then lead to a letter or case
study in a publication, a presentation to col-
leagues at a meeting or a telephone conversa-
tion with a medical school faculty member.
Each of these avenues can precipitate a
change in medical practice. Consider our thera-
peutic friend, aspirin. Clinical observations
have accounted for these dramatic understand-
ings in the use of this ubiquitous drug within a
generation: aspirin as a cause of chronic gastritis;
aspirin as an etiologic factor in Reye’s syn-
drome (a post-infectious
encephalopathy of children); and
aspirin as a preventive agent in
coronary thrombosis.
After billions of doses of aspirin,
clinicians might well have turned
to other potential answers for their
observations . Fortunately our prac-
tice advanced and a revision of the
text was necessary. IMl
Richard Nelson, MD
Iowa Medicine Volume SS / 6 June 7995 255
Iowa [Medicine
Classified Advertising
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50021; 800/729-7813 or 515/964-2772.
Beaver Dam, Wisconsin — Medical Associates
of Beaver Dam is actively recruiting a BE/BC
family physician to join its staff of 6 family
physicians. Gall is shared equally and all
hospital admissions are at our local 100-bed
hospital. Beaver Dam is a safe, family-oriented
community of 15,000 located 45 minutes
north of Madison with excellent schools and 4
season recreational opportunities. Excellent
compensation and benefits are provided. For
more information please contact Scott M.
Lindblom, Medical Staff Recruiter, Dean
Medical Center, 1808 West Beltline Highway,
1/800-279-9966, 608/259-5151, fax 608/259-
5294 or at home 608/833-7985.
Madison, Wisconsin — Dean Medical Center, a
300-physician multispecialty group, is seeking
additional family physicians to join its 30-
member department. Positions are located at
our Arcand Park, East Madison and Deerfield
Clinic locations. All positions have an
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For more information contact Scott M.
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9966, 608/259-5151 or at home 608/833-7985.
An Equal Oportunity Employer.
Physician/Associate Director — The University
Health Service, Northern Illinois University
has a full-time opening for an associate
director of their ambulatory health care
facility. The position is approximately 80%
direct provision medical care and 20%
administrative. Qualified applicants must be a
board certified physician and have or be
eligible for Illinois licensure. Broad spectrum
of training and clinical experience in primary
care required. Preference given for significant
experience in college health or ambulatory
care setting that includes high percentage of
diverse young adults. Must have strong
communication, interpersonal and clinical
skills. Send letter of interest, curriculum vitae
and 3 references to Charles E. Bowen,
Director, University Health Service, NIU,
DeKalh, Illinois 60115, 815/753-1314.
Applications accepted until position filled. EOE
256 Iowa Medicine Volume 85 / 6 June 7995
Emergency Medicine
Locum Tenens
Seeking quality physicians interested in
emergency medicine practice or primary
care locum tenens. Full-time and regu-
lar part-time. Numerous Iowa locales.
Democratic group, highly competitive
compensation, paid St. Paul malprac-
tice with unlimited tail, excellent ben-
efit package/bonuses to full-time phy-
sicians. Contact ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021.
Phone 1-800/729-7813 or 515/964-2772.
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Family Practice, Carroll, Iowa — Outstanding
professional opportunity for family practice
physicians in a progressive, safe and clean
community of 10,000. These opportunities
are available for either experienced family
practice physicians, or the family practice
physician just beginning practice. Excellent
schools (Catholic and public), quality hospital
and significant income potential available. For
more information, call Patricia Kalkhoff, Vice
President at 1-800/382-4197 or write St.
Anthony Regional Hospital, South Clark
Street, Carroll, Iowa 51401.
Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: acute/urgent
care, family practice, oncology/hematology,
orthopedic surgery and general internal
medicine practice. The Mankato Clinic is a
70-doctor multispecialty group practice in
south central Minnesota with a trade area
population of +250,000. Guaranteed salary
first year, incentive thereafter with full range
of benefits and liberal time off. For more
information, call Roger Greenwald, Executive
Vice President, at 507/389-8500 or Byron C.
McGregor, Medical Director, at 507/389-8548
or write 1230 East Main Street, P.O. Box 8674,
Mankato, Minnesota 56002-8674.
CLASSIFIED ADVERTISING
LeMars , Iowa
Seeking quality physicians to prac-
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Director and staff positions. Full
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age/bonuses to full-time physicians.
ACUTE CARE , INC., P.O. Box 515,
Ankeny, Iowa 50021; phone 800/
729-7813.
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
: Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
' Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management sendees and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Time For a Move?— BC/BE FP, IM, OB/GYN,
PEDS. Our promise — We’ll save you valuable
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9am-8pm, Sat 1-5 pm EST. 800/880-2028, Fax
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Family Practitioner — Fairfield, Iowa. Board
certified/board eligible to join one of 2 busy
successful clinics located next to hospital.
Fairfield is the county seat with a rural
population of 100,000. A university town,
situated in the tree covered hills of southeast
Iowa. There are 3 state parks within 30 miles.
Fairfield’s schools rank among the best in
Iowa. Call or write Walter Brownlee, CEO,
Jefferson County Hospital, P.O. Box 588,
Fairfield, Iowa 52556; 515/472-4111.
Janesville, Wisconsin, Urgent Care —
Riverview Clinic, a division of Dean Medical
Center, is actively recruiting an urgent care
physician to join its medical staff. We recently
increased our compensation package which is
based on a 40-hour work week. Total
compensation for Year 1 $108, 000, Year 2
$134,642 and Year 3 $135,000. We currently
have two physicians which staff the clinic from
9:00 a. m. -9:00 p.m. Monday through Friday
and 9:00-11:30 a m. on Saturday and desire to
expand the hours of operation until 9:00 p.m.
on Saturday and 1:00-9:00 p.m. on Sunday.
Our facility is brand new and well equipped
with 8 exam rooms, lab and x-ray. Flexible
hours are available with an expected total of
30-40 hours per week. Excellent compensa-
tion and benefits are provided. For more
information contact Scott M. Lindblom, Dean
Medical Center, 1808 West Beltline Highway,
Madison, Wisconsin 53713, work phone 1/800-
279-9966 or 608/259-5151, fax 608/259-5294,
home 608/833-7985.
Lancaster, Wisconsin — Dean Medical Center,
a 300+ physician private multispecialty group,
is actively recruiting for one board eligible/
board certified family physician to practice at
the Grant Community Clinic in Lancaster,
Wisconsin (population 4,200), an affiliated
clinic of Dean Medical Center. Their current
staff consists of 3 family physicians and one
general surgeon. The group also has 2
physician assistants on staff. Each physician
is at the clinic 6 hours a day, 4 days per week,
seeing between 20-25 patients daily. A
minimum $110,000 guaranteed salary plus
incentive is provided. For more information
please contact Scott M. Lindblom, Medical
Staff Recruiter, Dean Medical Center, 1808
West Beltline Highway, 1/800-279-9966, 608/
259-5151, fax 608/259-5294 or at home 608/
833-7985.
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
of Des Moines. We have a beautiful new
facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
Family Practice Opportunity
Perry Memorial Hospital
Princeton, Illinois
BC/BE family practitioner needed immed-
iately for full practice in this friendly
community. Practice includes:
• Competitive salary and benefit package
• Call schedule of 1:4
• 35,688 person draw area
• Affiliation with 98-bed, JCAHO accred-
ited Perry Memorial Hospital.
Princeton, Illinois offers high quality
schools and a safe environment in which to
live and work, as well as various cultural
and recreational activities. Contact:
Marie Noeth at 800/438-3745
or fax your CV to 309/685-2574.
Madison, Wisconsin, Urgent Care — Dean
Medical Center a 300+ physician
multispecialty group is seeking full time
physician to assist in staffing our two urgent
care centers. Qualified applicants should be
BE/BC in family practice, emergency medicine
or internal medicine with experience in
pediatrics. Dean Medical Center operates two
Urgent Care Centers 365 days per year, from
7:00 a m. -10:00 p.m. All physicians employed
at the urgent care centers are paid on an
hourly basis and full time physicians are
eligible to go on a shareholder track and buy
into the corporation after two years of
employment. Excellent compensation and
benefits with shareholder eligibility after two
years of employment. For more information
contact Scott M. Lindblom, Dean Medical
Center, 1808 W. Beltline Highway, PO Box
9328, Madison, Wisconsin 53715-0328, at
work 1/800-279-9966 or 608/259-5151 or
home 608/833-7985.
Advertising Rates and Data
Regular classified advertising sells for $2.00
per line with a $30 minimum per insertion.
For members of the Iowa Medical Society
the rate is $20 per insertion Display
classified advertising sells for $25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Inborn \ 1 1 , 1 i i '> > > i > il i r lyi e \ / A (it n/> 7 00^ 5K7
Iowa [Medicine
CLASSIFIED ADVERTISING
Orange City, Iowa
Exceptional opportunity for full-
time family practice physician to
join an 8-provider family prac-
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hospital via employment contract
with excellent benefit package.
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Orange City Hospital and Clinic
400 Central Avenue NW
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712/737-5270
Ramsey Clinic — A 250-physician multi-
specialty group based in downtown St. Paul
operates a small network of clinics in
Maplewood and western Wisconsin. We
currently have 2 openings for board certified/
board eligible family physicians at Ramsey
Clinic-Maplewood and the Family Medical
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Excellent call schedule, a first year salary
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Clinic, 640 Jackson Street, St. Paul, Minne-
sota 55101 or call 612/221-4230.
Janesville, Wisconsin — Dean Medical Center,
a 300-physician multispecialty group, is
actively recruiting additional BE/BC internal
medicine physicians to practice at the
Riverview Clinic locations in Janesville, Milton
and Delavan, Wisconsin. Traditional internal
medicine and urgent care practice opportuni-
ties are available. Janesville, population
55,000, is a beautiful, family-oriented
community with excellent schools and
abundant recreational activities. Excellent
compensation and benefits are provided with
employment leading to shareholder status.
Send CV to Stan Gruhn, MD, Riverview Clinic,
PO Box 551, Janesville, Wisconsin 53547 or
call 608/755-3500. An Equal Opportunity
Employer.
Stoughton, Wisconsin — Dean Medical Center,
a 350-physician multispecialty group is
actively recruiting a BE/BC family physician
for our Stoughton Clinic, which is located
approximately 20 miles south of Madison
(population 190,000). Currently there are 3
internists, 4 family practice physicians, one
pediatrician and one general surgeon at this
clinic. Call would be shared equally among
the family physicians. The Stoughton Hospital
is a 50-bed facility adjoining the new medical
office building. Stoughton has a population of
approximately 9,000 and growing with
excellent schools and neighborhoods. This is
an excellent position which enables you to live
in a safe community with the cultural and
professional resources of a larger city just
minutes away. A two-year guaranteed salary
plus incentive and benefits is being offered for
this position. Contact Scott Lindblom, Dean
Medical Center, 1808 West Beltline Highway,
Madison, Wisconsin; 1-800/279-9966; 608/250-
1550 (work); 608/833-7985 (home); or fax
608/250-1441.
Springfield, Missouri — Bass Pro Shop and 40
miles to Branson. BE/BC FPs. OB optional,
salaried position and production bonus, call
1:7, teaching hospital, university community.
Contact Vivian M. Luce, Cejka & Co., 1/800-
765-3055 or fax CV for immediate attention to
314/726-3009 (IMs welcome).
Emergency Medicine
Administrative Opportunity
Ottumwa, Iowa
Exceptional opportunity for primary care
trained or experienced emergency physician.
• 19,000 Annual Volume
• 12-Hour Shifts
• Double Coverage
• New Department
• Flexible Scheduling
• No Call Responsibility
• Generous Compensation Package
• Paid Malpractice Insurance
• Health /Dental, Life, Disability
Send CV or call Sheila Jorgensen
EMERGENCY PRACTICE ASSOCIATES
PO Box 1260, Waterloo, Iowa 50704
800/458-5003 or fax 319/236-3644
Boone , Iowa
Seeking a quality emergency physician
interested in a stellar emergency medi-
cine practice. Full and regular part-
time position available. Democratic
group, paid St. Paul malpractice with
unlimited tail. Excellent benefit pack-
age/bonuses to full-time physicians.
Average volume with above-average
compensation. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021;
phone 800/729-7813.
Janesville, Wisconsin — Dean Medical Center,
a 300-physician multispecialty group, is
actively recruiting additional BE/BC family
physicians to practice at the Riverview Clinic
locations in Janesville, Milton and Delavan,
Wisconsin. Traditional family practice and
urgent care opportunities are available.
Janesville, population 55,000, is a beautiful,
family-oriented community with excellent
schools and abundant recreational activities.
Excellent compensation and benefits are
provided with employment leading to
shareholder status. Send CV to Stan Gruhn,
MD, Riverview Clinic, PO Box 551, Janesville,
Wisconsin 53547 or call 608/755-3500. An
Equal Opportunity Employer.
Emergency Medicine — Outstanding opportuni-
ties in emergency medicine available in a
variety of Iowa and Minnesota locations for
primary care trained or experienced emer-
gency physician. Quality lifestyles in family
oriented communities. Guaranteed compensa-
tion, paid malpractice, health/dental, life,
disability. Send CV or call Sheila Jorgensen.
Emergency Practice Associates, P.O. Box 1260,
Waterloo, Iowa 50704; 800/458-5003, fax 319/
236-3644.
115-Physician, Midwest Multispecialty —
Seeking BC/BE candidates: dermatology,
family medicine, pulmonology. Comprehen-
sive health care center for 14 counties,
population over 320,000. Two-year guaran-
teed salary, relocation and CME funds part of
the many benefits. Safe, thriving family
community with stable economy offers a
rewarding quality of life. Purdue University
offers academics, cultural events and Big 10
sports. Physician Recruitment, Arnett Clinic,
PO Box 5545, Lafayette, Indiana 47904; 800/
899-8448.
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Iowa [Medicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrey, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy' Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljko K. Zivkovich, MD
Robert A. Colnian, MD
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Robert J. Barry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Bligard, MD, FAAD
James D. Bunker, MI), FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milner-Brage, Ml)
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gcrvich, MD
Daniel J. Schrocder, MD
Ravi K. Vemuri, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOB1M
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MD, ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MD
Laurence S. Krain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, Ml), MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery’
James R. Lamorgesc, Ml)
Loren J. Mouw, Ml)
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Hosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
260 Iowa Medicine Volume 85/ 6 June 1995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Haync, Ml)
Thomas A. Carlstrom, Ml)
David J. Boarini, Ml)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, Ml)
S. Randy Winston, MD
Douglas R. Koontz, Ml)
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad I). Abernathey, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell H. Watt, MD
John M. Graethcr, MD
Gilbert W. Harris, MD
James A. Davison, MD
Norman F. Woodlief, Ml)
Erie W. Bligard, MI)
David D. Saggau, Ml)
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert I). Whinerv, MI)
Stephen II. Wolken, MD
Robert B. Goffstcin, MI)
Lyse S. Strnad, MD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MI)
Randall S. Brcnton, Ml)
James L. Duinmett, MD
Mick E. Vandcn Bosch, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MI)
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Iowa Orthopaedic Center, PC
Marvin II. Dubansky, MD
Marshall Flapan, MD
Sinesio Misol, MI)
Joshua D. Kimclman, DO
Timothy G. Kenney, Ml)
Lynn M. I. indaman. MD
Jeffrey M. Farber, Ml)
Kvlc S. Galles, MI)
Scott A. Meyer, MD
Cassini M. Igram, MD
Donna J. Bahls, MD
Jill R. Meilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Orthopaedic Suigery
Fort Dodge Medical Center, PC
C. Mark Race, Ml)
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Otolaryngology
Iowa ENT, PC
Thomas A. Ericson, MD
Marshall C. Greiinan, MD
Steven R. Ilerwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Ilill, MD
Daniel J. Blum, MI)
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85/6 June 1 995 261
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MD
Eugene Peterson, MD
Richard B. Merrick, MD
Peter V. Boesen, MD
Robert R. Llpdegraff, MD
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolarvngology-llead & Neck
Surgery, PC
Thomas J. Benda, Sr., MD
James W. White, MD
Craig C. Hcrthcr, MD
Thomas J. Benda, Jr., MI)
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MI)
Guy E. McFarland, MD
Thomas F. Viner, MI)
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Physical Medicine &
Rehabilitation
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice D. Schnell, MD
Farccduddin Ahmed, MD
Arthur B. Searle, MD
Bogdan E. Krysztofiak, MD
Rehabilitation Medicine Associates
William I). dcGravellcs, Jr., MI)
Charles F. Denhart, MD
Marvin M. Hurd, MD
William C. Koenig, Jr., MD
Karen Kienker, MI)
Todd C. Troll, MI)
Lori A. Sapp, MI)
Younkcr Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
Surgery
Wendell Downing, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warliek, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MI)
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matvsik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary Diseases
Advertising Index
Bemie Lowe & Associates 254
Blue Cross Blue Shield 252
Dale Clark Prosthetics 263
IMS Sendees 226
Medical Records
Assistance Services 246
Medical Management
Strategies, PC 230
MMIC 264
Monroe Clinic 249
Muleahy's Jeep/Eagle 259
U.S. Air Force 246
U.S. Army Reserve 230
262 Imon. Mp/iininp
Vnhi.m.p ft ft /
limp 199ft
Iowa [Medicine
THE PRESIDENT COMMENTS
Three important
issues
This month’s Iowa Medicine contains a
guest editorial by Dr. Paul Seebohm re-
garding the IMS Education Fund. The
fund supports very worthwhile projects, in-
cluding student loans. These loans are relatively
low interest (7% this year) and play an impor-
tant part in financing of many junior and senior
medical student’s education.
Current proposed federal legislation would
require that interest on federal student loans be
paid annually from the inception of the loan.
Should this pass Congress, loans from the IMS
Education Fund will be even more desirable.
The average formal loan debt load of cur-
rently graduating University of Iowa medical
students is approximately $50,000. That seems
staggering (but I’m not 26 or 27 years old).
The number of loans on which
there has been a default is re-
markable— one, only one. Any
banker would be envious. Obvi-
ously this speaks to the quality
and character of the recipients.
Many Iowa physicians were ei-
ther the recipients of these loans
or had a friend that was. I am sure
we realize the importance of maintaining the
capitalization of these funds. Dr. Seebohm says
we will be hearing more from him and his
committee in the future. Let us respond gener-
ously when we do.
Those of you who attended the IMS Annual
Meeting heard Dr. Richard Corlin speak. Dr.
Corlin is vice speaker of the AMA House of
Delegates and a gastroenterologist practicing in
California. I am continually impressed by the
high caliber of physicians who serve as trustees
and officers of the AMA. They are capable, well
informed and well spoken. Dr. Corlin made a
comment about the AM News. If you are like
me, about the last thing I need is one more
journal or paper to read. However, he pointed
out, the first four pages of AM News is particu-
larly worthwhile reading to keep well informed.
He also stated very succinctly the two main
current issues facing medicine and society;
one, in what form and how will health care be
delivered, and two, how will we be compen-
sated. In California, he noted managed health
care is dominant; in some areas 90 to 95% of the
population is covered by this form of health
care delivery system.
On May 24, the Board of Trust-
ees met with the representatives
of the Iowa Foundation for Medi-
cal Care. As instructed by the
House of Delegates, we requested
that next year we receive a report
from them at our Annual Meeting.
They will be pleased to do so.
Unfortunately, poor communica-
tion was responsible for their absence this year.
We discussed the current approach of HCFA
called Health Care Quality Improvement Pro-
gram (HCQIP). This approach stresses quality
improvement through education, sharing in-
formation among physicians and education of
patients about their choices. Let’s hope this is
an improvement over past “medical care evalu-
ation”. u
The first
four pages of
AM News is
particularly
worthwhile
reading.
Joseph Hall, MD
Iowa Medicine Volume 85/ 7 July 1995 271
rincipa!
Financial
~ ~ , c? o, on-i
Chart a
healthy
course .
Your help is
needed!
Next October, a major campaign will be
initiated by the IMS to raise money for
use by the IMS Education Fund.
This new fund-raising initiative is necessary
because over the past 15 years the programs
supported by the IMSEF have almost tripled,
i\ while contributions to the Fund have remained
about the same.
Each year, approximately 450 IMS members
make voluntary contributions amounting to
$ 22,000 . There are also periodic contributions
via memorial bequests and special donations
from county societies and others. An annual
income of approximately $13,000 a year comes
to the Fund from a special trust.
Although the payback to the medical stu-
dent loan fund has been exemplary, the IMSEF
has had to draw heavily on its
reserves to meet the demands of
ongoing and new programs. It is in
need of an infusion of more mon-
ies into the system.
If you’re unfamiliar with the
fund, here’s some background in-
formation:
• The IMSEF was created in
the early 1950s. Included within its structure
are the George H. Scanlon Medical Student
Loan Fund, the Henry Albert Benevolence and
Public Health Fund and a non-designated fund.
• The major activity of the Fund is the
student loan program. In 1994-95, $240,000
was loaned to 43 students. Since the inception
of the program, over 800 loans amounting to
$2.7 million were awarded. Requests for loans —
both in numbers and amounts — are increasing
every year. If there are additional cuts in
federal financial assistance programs, the avail-
ability of private support will become even
more important.
• In addition to loans to medical students,
the IMS Assistance Program for Troubled Phy-
sicians receives support from the Fund, as does
the IMS Scientific Session and Iowa Medicine
(journal of the IMS.) Various public health
education projects are also financed — e.g., child
abuse identification, domestic violence, health
care for the elderly, drug abuse and others.
There will be several ways you can give, and
I urge you to begin thinking about how you will
participate. In addition to tax-deductible cash
gifts, there are various options for deferred
giving which allows the giver both
a charitable tax deduction and a
valuable donation, without forfeit-
ing current needed income.
Several other IMS past presi-
dents have joined me in the devel-
opment of this fund-raising effort.
These physicians are: Hormoz
Rassekh, MD, Council Bluffs; Don
Rodawig, MD, Spirit Lake; John Tyrrell, MD,
Manchester; and Dennis Walter, MD, Des Moines.
You’ll be hearing from us! Q3
In addition to
tax-deductible
cash gifts, there
are various
options for
deferred giving.
GUEST EDITORIAL
Paul Seebohm, MD
Dr. Seebohm is professor
emeritus in the Depart-
ment of Internal
Medicine, UI College of
Medicine in Iowa City.
He is also chairman of
the fund-raising
committee for the IMS
Education Fund.
Iowa Medicine Volume 85 / 7 July 1995 2 73
Iowa [Medicine
IMS Update
AT A GLANCE
The American Medical
Association is continuing
its two-year Study of the
Federation. John Rhodes,
Jr., MD represents the
IMS on the Consortium.
Reportedly, Consortium
participants generally
support experimentation
with changes in the
structure of organized
medicine.
•
The final death toll from
the Oklahoma bombing
was 167; 19 were chil-
dren. Over 4,000 persons
were injured, but few of
those remain hospital-
ized. The attention of the
medical community is
now turning to the mental
health of those involved
in the tragedy.
IMS Directory verification letters due
July 14 is the deadline for returning your
IMS member verification letter. The letter
verifies member information for IMS records
and the IMS Membership Directory. The let-
ter was mailed to all physicians in early June.
The letter asks for information including
practice address, telephone and fax numbers,
clinic name, physician social security num-
bers and other information which will help
IMS be more responsive to member needs.
This year, the letter also asks for the name
of your senior clinic administrator.
It is important that you return your letter
to ensure the correct information about your
practice appears in this year’s directory. The
1995-96 IMS Membership Directory will be
distributed to all IMS physicians in October.
If you misplaced your letter or did not
receive one, call Sherval Westbrook or Sandy
Nelson at the IMS, 515/223-1401 or 800/747-
3070 to verify your information.
Specialty representation in IMS House
At the April IMS Annual Meeting, the
House of Delegates approved a proposal to
allow for representation for state specialty
organizations in the IMS House of Delegates.
The IMS Board of Trustees is in the
process of working out the details of that rep-
resentation so that eligible state specialty
organizations can apply for representation at
the 1996 IMS House of Delegates.
Watch future issues of Iowa Medicine for
further details.
IMS domestic violence video available
The Iowa Medical Society’s 27-minute
videotape “Break the Silence; Begin the
Cure” on domestic violence is available for
loan to any Iowa physician. Call Chris
McMahon, IMS director of communications,
at 515/223-1401 or 800/747-3070.
IMS cosponsors conference on aging
The IMS cosponsored the 1995 Governor’s
Conference on Aging held last month in Des
Moines. The program was attended by over
550 people, including professionals who deal
with programs for the elderly.
Eugene Lehrmann, president of the
American Association of Retired Persons,
was a guest speaker. He discussed the goals of
AARP, emphasizing that AARP does not want
to preserve programs for the elderly at the
expense of their children and grandchildren
and is working on solutions which do not
unfairly burden succeeding generations.
Specialty Society Update
The IMGMA Spring Educational Meeting, held May
3-5 at the Des Moines Marriott, drew a record
attendance of 310. Including exhibitors, there
were 470 registrants. Fritz Wenzel, executive
director of the Medical Group Management
Association, was keynote speaker. The Executive
Council is scheduled to meet July 11 in Des
Moines. The Fall Meeting is September 13-15 at
Lake Okoboji.
The Iowa Psychiatric Society has concluded negoti-
ations with Medco Behavioral Health Corporation of
Iowa for contracts with Iowa psychiatrists. The IPS
was able to win several improvements in the con-
tract. Call Dana Petrowsky for more information,
515/223-2816. The Executive Council will meet
July 12 in Des Moines. The Fall Annual Meeting is
scheduled for October 27-28 in Iowa City.
The American Medical Directors Association, Iowa
Chapter, Spring Meeting was April 21. The program
focused on depression and anxiety in the elderly.
Iowa Oncology Society President Dr. George Kovach
and Dr. Dean Gesme attended the American Society
of Clinical Oncology Annual Meeting in Los Angeles
May 20-23. National practice standard guidelines
and CPT coding were discussed.
The Executive Committee of the Iowa Pathology
Association met June 15 at IMS headquarters.
Discussions were held to contract with IMS
Services, Inc. for staff support of the Association.
274 Iowa Medicine Volume 85 / 7 July 1995
CURRENT ISSUES
Focus on IMS Alliance
The IMS Alliance has completed another suc-
cessful annual meeting. The basket auction for AMA
Education-Research Fund raised $2,277. A check
for $18,851 was presented to Dr. Robert Kelch,
dean of the U of I College of Medicine.
The following IMS Alliance members were select-
ed to serve as delegates to the AMA Alliance Annual
Session of the House of Delegates in Chicago in
June: Barbara Bell, Des Moines; Linda Miller,
Davenport; Karen Messamer, Oskaloosa; Cindy
Ehrecke, LeClaire; and Ann Crouch, Spencer. Kathy
Beaty, Clive and Gretchen Graham, Iowa Falls, will
attend as alternate delegates. I will report on this
meeting next month.
I invite all medical spouses to our summer board
meeting July 19-20 at Comfort Suites Living History
Farms, Urbandale. Child care will be available. The
meeting will focus on health promotion projects for
the coming year. Patti Herlihy of Rapid City, SD will
be our keynote speaker. She serves on the national
health projects committee and will be discussing
SAVE Today (Stop All Violence Everywhere), set for
October 11, 1995.
Contributed by Linda Miller, president, IMSA
Red Cross seeks volunteers
The American Red Gross and the Des
Moines Fire Department are organizing a vol-
untary team to provide support for Des
Moines EMS services in the form of trans-
portation to local hospitals for non-emer-
gency patients and grief counseling to family
and friends in the case of a death of natural
causes.
The purpose of the program is to relieve
the EMS team and hospital personnel so they
are available for emergency calls. Any physi-
cian who knows someone who may be inter-
ested in this new program is urged to call
Margie Conrad, American Red Cross director
of volunteer services, 515/224-6700. IE3
July 14 is the
deadline for
returning your IMS
1995-96
Membership
Directory
verification letter.
In the 1994 elections, IMPAC contributed over S66,000 to 114 candidates running for state
office. IMPAC contributed to 105 winners for a 92% success rate. Obviously, contributions from
Iowa physicians were well spent.
Here’s where
the real
battles are
being
fought
But we cannot stop there. The 1996 elections are just around the comer. We cannot afford to
let the interest of medicine be overshadowed by the banter of political rhetoric. The strides
made by IMPAC in 1994 must be sus-
tained through 1996 if Iowa physicians
are to be heard by their lawmakers.
If doctors abdicate responsibility to par-
ticipate in the political process, it is
certain that non-physician groups will
take our place. They have already be-
gun their fund-raising and grass roots
work for 1996 and we cannot afford to
fall behind now.
The time has come to step forward and
be heard through a strong IMPAC.
Join IMPAC today!
Iowa Medicine Volume 85 / 7 Julv 7995 275
Iowa | Medicine
Futures
AT A GLANCE
Allen Health Systems,
which includes Allen
Memorial Hospital in
Waterloo, plans to
merge with Iowa Health
System, which is com-
posed of Iowa Methodist
Medical Center, Iowa
Lutheran Hospital (both
in Des Moines) and St.
Luke ’s Hospital in
Cedar Rapids. This will
give the new organi-
zation nearly 2,000 li-
censed beds and over
8,000 employees.
A coalition of central
Iowa-based employers
called the Community
Health Purchasing Cor-
poration (CHPC) rec-
ently held an informa-
tional meeting in Des
Moines. The group is
coordinated by the
Health Policy Corpor-
ation of Iowa. The group
supports a number of
concepts, including
increased purchaser/
provider communica-
tion, fair and negotiated
prices that reward
appropriate care and
consumer-driven com-
petition.
276 Fnvoin Mcrlit'inp
PPRC recommends single conversion factor
Physician fees will be computed using only
one update factor rather than three, if
Congress accepts the Physician Payment
Review Commission’s recommendation.
PPRC is recommending a single factor for pri-
mary care, surgical and non-surgical sendees.
PPRC also recommends a single fee update
for all physician sendees for 1996 instead of
separate updates for surgery, non-surgery and
primary care.
Over the long term, PPRC wants Congress
to change the method of adjusting the factor
by using something similar to the gross
domestic product instead of the volume per-
formance standard.
In addition, they recommend using the
conversion factor to adjust fees for budget
neutrality rather than the relative value units.
People “crowding” into HMOs
The Chicago Tribune recently reported
that people are crowding into IIMOs and flee-
ing escalating costs of traditional fee-for-ser-
vice health care, but once high-flying stocks
of HMO companies have taken a dive.
Since March, the market value of HMO
stocks has fallen 25%. As prices rise on every-
thing from catheters to CAT scans and
employers and insurers squeeze premiums,
investors fear many HMOs could wind up on
the financial critical list.
Most publicly traded HMOs remain prof-
itable, but unpleasant earnings reports from
several are seen as harbingers of hard times.
Also on the HMO front, a recent Los
Angeles Times article questioned whether or
not HMO physician reimbursement tactics
jeopardize the quality and amount of care
given to patients in medical need. The article
cited a case in Simi Valley, California where
a woman with abdominal pain and rectal
bleeding was never tested by her doctor for
serious medical problems.
Medicare fees recommendation
Donna Shalala, secretary of Health and
Human Services, has recommended to
Congress that physicians’ fees be increased
by 1.1% for all medical services in 1996. The
update recommendation would require
Congress to change the law covering
Medicare’s payments to physicians.
If Congress does not enact the recommen-
dation, the default formula would go into
effect resulting in estimated updates of a 3.9%
increase for surgical services, a 2.2% decrease
for primary care and a 0.6% increase for non-
surgical services.
AMA trustee testifies on Medicare
“The Medicare program urgently requires
serious, lasting change if its promise is to be
preserved for current and future generations
of Americans,” Dr. Nancy Dickey, vice chair
of the AMA Board of Trustees, told the Senate
Finance Committee recently.
Dr. Dickey said three factors have pushed
the Medicare program to its current “perilous
point”: demographics, new technology and
the increased demand for a wide range of
health services.
The AMA is proposing a new partnership
in which patients, physicians, business and
the government work together to develop
rational and effective long-term solutions to
Medicare’s financing problems.
The AMA believes Medicare reform must
adhere to five basic principles:
•Encourage beneficiary cost-conscious-
ness.
•Increase price competition among
providers.
•Reduce intergenerational inequity in
financing.
•Test ways of reducing future generations’
dependency on Medicare.
•Reduce regulatory and administrative
complexity. U3
Vnlu-mp SS / 7 tul\, 1QQS
CURRENT ISSUES
C H M I S Update
As part of the Iowa Medical Society’s ongoing effort to educate Iowa physicians about the
Community Health Management Information System (CHMIS), this CHMIS Update page will be a
regular feature in Iowa Medicine.
IMS ACTIVITIES
Iowa Medical Society leadership and
staff continue CHMIS activities and discus-
sions of key CIIMIS issues of concern to
Iowa physicians.
Recently, in response to IMS inquiries,
the CHMIS Governing Board confirmed
that ERISA plans have been put on notice
that they are expected to participate in
CIIMIS as of July 1, 1996. ERISA regulates
self-insured plans. Everyone involved is
hopeful they will voluntarily participate in
order to gain the advantages of electronic
billing and insurance verification for this
group of patients.
Also, at its recent meeting, the IMS
Board of Trustees discussed in detail the
advantages of a single CIIMIS network or
multiple networks. The Board reaffirmed
the House of Delegates position that multi-
ple networks are in the best interest of
physicians and the CHMIS. However, the
Board acknowledged that there is dissent-
ing opinion among some IMS members
that a single network would be preferable.
The Board will continue its close involve-
ment in this and other CHMIS issues.
Finally, it was learned that the Hartford
Foundation has approved another year of
CHMIS funding.
CHMIS ADVISORY COMMITTEE ACTIVITIES
(IMS staff are observers at all advisory
committee meetings and work groups.)
•Ethics and Confidentiality
This advisory committee continues
work on a policy for release of data and
identifying potential users of data.
Generally, the policy protects patient-spe-
cific data as provided in CHMIS law, but
does not protect provider-specific data.
work on the Request For Proposal (RFP)
for the CIIMIS data repository. The RFP is
expected to be presented for approval by
the CHMIS Governing Board in August.
Data repository bidders will be given 30
days to respond; the Governing Board will
award the repository contract in October
or November.
This group has reviewed data elements
to be collected in the repository and has
struggled with how much storage will be
needed. One difficulty is determining the
number of providers who will eventually be
involved with CIIMIS and their volume of
patient encounters.
It has been confirmed that insurance eli-
gibility will be a Phase I activity, but will
probably be limited to insurance informa-
tion and not include status of deductibles
and coinsurance.
Early indications are that Phase I will
initially involve claims data only and
encounter based information will evolve at
a later date. It is anticipated that the data
repository will store the results of the
health status and consumer satisfaction
surveys.
The Network Certification work group
has been refining the Electronic Health
care Network Accreditation (EIINAC) stan-
dards and has met with potential network
vendors.
Also, the committee has decided net-
works would not be required to encrypt
data as they carry out transfer responsibil-
ities. The data repository would need to
encrypt data. Data editing is best per-
formed at the provider site.
•Technical Advisory
This advisory committee continues
on your horizon July 1, 1996
YOUR representatives
on state CHMIS
committees:
CHMIS
Governing Board:
Dale Andringa, MD
Des Moines
515/241-4102
Beth Bruening, MD
Sioux City
712/233-1529
CHMIS advisory
committees:
Communications/
Education
Laine Dvorak, MD
Data Advisory
William Bonney, MD
John Brinkman, MD
Ethics/Confidentiality
Charles Jons, MD
Quality Review
Elie Saikaly, MD
William Langley, MD
Technical Advisory
Thomas Menzel, MD
Mark Purtle, MD
IMS CHMIS
Committee:
Terrence Briggs, MD (chair)
IMS staff:
Barb Heck
Ed Whitver
Dean Gillaspey
Iowa Medicine Volume 85 / 7 Julv 1995 277
Iowa|Medicine
Legislative Affairs
CURRENT ISSUES
Managed care for substance abuse
AT A GLANCE
GOP hopefuls are rak-
ing in campaign cash.
Gramm has raised over
88 million; Dole isn’t far
behind. Experts believe
Dole will raise the most
before next year’s pri-
maries.
♦
The U.S. Senate is plan-
ning a probe of the
American Association of
Retired Persons. The
main issue is the AARP’s
tax-exempt status and
its unrelated business
income.
•
A recent opinion piece
in New York Newsday
prompted a letter from
AM A President Dr.
Robert McAfee, who
called the piece “ridicu-
lous”. The article
alleged that liability
reforms being consid-
ered by Congress would
take away citizens ’
rights to have a case
heard. The simple rea-
son trial lawyers want
things to stay as they
are, said Dr. McAfee, is
because they “walk
away with 8333,000
of every 81 million
award. ”
The state of Iowa is continuing its plan to
implement managed care for Title XIX sub-
stance abuse cases. An RFP for contractors
was released May 1. There have been two
bidders on the contract — Iowa Health
Systems (in partnership with Value
Behavioral Health and Midwest Behavioral
Management Services) and the National
Council on Alcoholism and Other Drug
Dependencies (in partnership with Medco
Behavioral Care). Value Behavioral Health
and Medco were bidders for the state’s highly
controversial mental health managed care
contract.
Title XIX plans to implement managed
care for substance abuse cases on September
1, 1995.
IMS among groups discussing PPA
The Iowa Medical Society continues to
meet with large employers in Iowa to gain
their support for the principles in the AMA’s
Patient Protection Act.
The IMS is part of a work group drafting a
joint statement regarding patient and
provider protections under managed care.
The work group includes the IMS, the Iowa
Hospital Association, Blue Cross and Blue
Shield of Iowa, Principal Health Care of Iowa,
SecureCare, Heritage National Healthplan
and John Deere Family Health Plan.
The group recently finished its second
draft. This draft has been approved by the
IMS Board of Trustees, pending approval by
other groups. Watch future issues of Iowa
Medicine for the full text of the agreement as
soon as it is finalized.
Other states have chosen to pursue legisla-
tion based on the Patient Protection Act
rather than the voluntary approach taken by
the Iowa Medical Society and other organiza-
tions. However, according to a recent article
in the Wall Street Journal, states which have
Contacts Needed With State
Senators Before Next Session
The IMS will continue to push for the reduc-
tion in the statute of limitations for minors in
the 1996 Iowa Legislature. An IMS-proposed
bill passed the House this session and has
been assigned to the Senate Judiciary
Committee. This means it remains alive for
1996. Physicians are strongly encouraged to
spend time with their senators before the
next session of the Iowa Legislature and help
them understand how important this reform
is to them and their patients.
attempted to enact the Patient Protection Act
as legislation have been less than successful.
Meanwhile, the AMA continues to push for
enactment of the Patient Protection Act at
the federal level. Dr. Lonnie Bristow, presi-
dent-elect of the AMA, said in a recent inter-
view that without the Patient Protection Act,
administrators — not doctors — of health
maintenance organizations are setting stan-
dards of patient care.
Health care access rules finalized
The Iowa Insurance Division has complet-
ed the process of promulgating administra-
tive rules to implement legislation requiring
that employers provide access to health
insurance coverage. This law became effec-
tive January 1, 1995.
Beginning May 1, 1995, any employer
doing business in Iowa who does not provide
health insurance to employees shall provide
to their regular full time or regular part time
eligible employees a written referral of where
those employees can get information on
health care. This written referral can be to a
health insurance agent, health insurance car-
rier or other health care organization.
Temporary employees, independent con-
tractors and minors are not included in the
list of eligible persons. Hxl
278 Iowa Medicine Volume 85 / 7 July 1995
Iowa|Medicine
CURRENT ISSUES
Medical Economics
Physicians provide “billions” in free care Preventive services on endangered list
More than two-thirds of American physi-
cians are providing over $21 billion in
uncompensated care to patients in financial
need, according to a report released by the
American Medical Association.
According to the AMA’s survey report,
307,650 physicians rendered over $11 billion
in charity or reduced-fee care to patients in
need during 1994 and absorbed an additional
$10 billion in services for which payment was
expected but never received.
Since 1988, AMA surveys have shown a
steady increase in the number of physicians
providing charity care and the amount of
time physicians spend per week rendering
free or reduced-fee care.
Across 10 specialty classifications, per-
centages of physicians who provide charity
care ranges from 60% to 74%. Surgeons and
radiologists most frequently provide charity
care. Rural or nonmetropolitan physicians
provide charity care more frequently (71%)
than urban physicians (67% to 68%).
Medicare claims processing conversion
Conversion to a new system of Medicare
claims processing for Iowa physicians has
reportedly gone smoothly.
However, there have been a few changes as
a result of the conversion. With the old sys-
tem, Medicare was able to change modifiers
that had been used incorrectly to expedite
the claim payment. The new system is not as
forgiving and Medicare must stay with stan-
dardized processing, which means claims
must be exact.
Some physician offices have reported that
the remittance notice is difficult to read
because of small print. Medicare is confident
this problem can be improved.
A special Medlnfo was mailed to all physi-
cian offices regarding the results of the con-
version. If your office has problems, call Mary
Reinsoen at the IMS.
Experts in preventive medicine fear that
some time-honored aspects of the annual
physical will soon be extinct.
An article entitled “Death of the Physical”
in a recent issue of LACMA Physician said
the following procedures are at special risk
since they have not been scientifically shown
to have significant benefits:
•Checking reflexes — Pertinent only for
patients with low back pain or other neuro-
logical symptoms.
•Routine ECG — Necessary only in some
cases, for example, men 40-64 with two or
more cardiac risk factors.
•Chest x-rays — Chances of positively
affecting outcome if an abnormality is dis-
covered are slim.
•Auscultation of lungs — Even for those
aged 65 and over, it isn’t recommended.
•Complete blood panel — Only nonfasting
blood cholesterol, dipstick urinalysis and thyroid
function test (for women) are recommended.
President proposes less paperwork
President Clinton wants to get ahead of
congressional deregulation and help reduce
paperwork for small businesses, according to
a recent Kiplinger Newsletter. He wants to
get credit for helping small businesses by
ordering agencies to trim fines for minor vio-
lations and cut the number of reports which
must be filed.
The FDA will no longer require environ-
mental assessments of drugs by manufactur-
ers or premarketing evaluations of new med-
ical devices that pose little risk. OSHA will
cut penalties 70% for firms with good safety
records and will cease nit-picking such as
$400 fines for not displaying posters.
Deregulation is usually proposed every 10
years but bogs down due to court challenges
and “foot-dragging bureaucrats who demand
more reports” says Kiplinger. El
AT A GLANCE
Tobacco industry > efforts
to turn back county -
wide anti-smoking ordi-
nances in Wichita Falls,
Texas were defeated at
the ballot box by the con-
certed efforts of the
Wichita County Medi-
cal Society, the Texas
Medical Association and
the AMA.
•
A recent Washington Post
article discussed the
“rancorous debate” that
surrounded medical lia-
bility reform legislation
in the House and Senate,
alleging that partici-
pants reached new
heigh ts in the art of influ-
encing politicians. As an
example, the article sin-
gled out the AMA’s Dr.
Maureen O’Regan ads.
Ironically, the Post
reprinted the AMA’s full-
page ad juxtaposing
nine Surgeons General
and Health Secretaries of
both parties all urging
caps on non-economic
awards.
Iowa Medicine Volume 85 / 7 July 1995 279
HMO
MEDICAL DIRECTOR
Community Health Plan is a non-profit commu-
nity owned HMO, being developed throughout
Northwest MO. We currently seek a half-time
Medical Director. If you can continue to practice
half-time and have managed care administrative
background (prefer HMO management experi-
ence), you should consider Community Health
Plan in St. Joseph, MO. Use your extensive
communication, leadership, and clinical skills.
This position is responsible for the day-to-day
clinical review activities of the Plan, medical care
delivery model development, chairing several
physician committees, and assisting our providers
in our communities with education and support
for our managed care activities.
Send resume to Community Health Plan,
5301 Faraon, St. Joseph, MO 64506, Attn:
Joan Copeland or call 800-990-9247.
Heartland
Health System
EOE
Medical Management . . .
For Maximum Return
Maximize profit, operations and
control for the 90s
Learn how to:
•Increase your practice’s bottom line by 1096 in 30 days
•Shorten your insurance claim turn-around
•Evaluate your practice’s present financial performance
•Establish medical and surgical fee schedules
•Evaluate managed care contracts
Three-way Guarantee
We will:
1. Increase your bottom line by #25,000 per physician
2. If after 30 days, you decide not to implement proposed
changes
3. If after 6 months, we have not delivered on every promise
You owe us nothing.
Call today for a confidential consultation:
1-800-863-2412
Medical Management Strategies, P.G.
Gary Nielsen, CPA
SURGEONS: COULD YOU USE AN EXTRA $10,000?
If you’re a resident in surgery, the Army
Reserve will pay you a yearly stipend which
could total in excess of $10,000 in the Army
Reserve’s Specialized Training Assistance
Program (STRAP).
You will have opportunities to continue
your education and attend conferences, and
we will be flexible about scheduling the time
you serve. Your immediate commitment
could be as little as two weeks a year, with a
small added obligation later on.
Get a maximum amount of money for a
minimum amount of service. Find out more
by contacting an Army Reserve Medical
Counselor.
CALL COLLECT CPT RICK OTTO
612-854-7702
ARMY RESERVE MEDICINE. BE ALL YOU CAN BE!
Iowa I Medicine
CURRENT ISSUES
Practice Management
New guidelines for CPT coding
Through July 31, 1995, Iowa’s Medicare
carrier will be phasing in implementation of
new CPT coding guidelines. Beginning August
1, evaluation and management (E/M) codes
will no longer be excluded from the Medicare
medial review system. Carriers will vary in
their timetables for utilizing the guidelines in
reviewing E/M services.
If evaluation and management review is
indicated, carriers will request medical
records for specific patients and encounters.
The documentation guidelines will be used as
a template for that review. If the documenta-
tion is not sufficient to support the level of
service provided, the carrier will contact the
physician for additional information.
Remember, the documentation guidelines
do not equate to medical necessity review,
which is a separate determination by the car-
rier. Medical necessity review may occur after
the carrier determines that the sendee was
rendered but not reported correctly.
Review of evaluation and management ser-
vices will occur only if evidence of significant
aberrant reporting patterns is detected
(based on national, carrier or specialty pro-
files).
All reviews are conducted on a “focused”
basis — there is no random review.
For more information on the new guide-
lines, call Barb I leek or Mary Reinsmoen at
the IMS, 515/223-1401 or 800/747-3070. El
Midwest Medical Insurance Company
Focus on Risk Management
Telephone advice
In most clinics, a great deal of advice is
given to patients over the telephone. Many
patient injuries and malpractice claims have
resulted from incorrect diagnoses and treat-
ments based on information obtained over
the telephone without benefit of a clinical
examination. To reduce your liability risks:
•Allow only physicians or trained staff to
handle telephone advice calls.
•Establish telephone triage guidelines that
outline how calls should be handled.
•Advise patients of the limitations of tele-
phone treatment and tell patients to call back
if their condition changes.
•Document all telephone advice calls in
the patient’s medical record.
•Ensure triage guidelines were followed by
reviewing staff documentation of advice calls.
One common problem many physicians
face involves how to ensure adequate after-
hours documentation of telephone advice.
Recommendations include:
•Use telephone message forms.
•Dictate telephone encounters immediately.
•Use office voice mail to dictate after-
hours advice calls.
For further information, contact Lori
Atkinson, MMIC risk management coordinator,
MMIC West Des Moines office, PO Box 65790,
West Des Moines, Iowa 50265, 800/798-9870 or
515/223-1482.
AT A GLANCE
Medical Computer Man-
agement, Inc. has
merged with CUSA
Technologies of Salt
Lake City. The merger
brings additional bene-
fits to MCMI customers
in Iowa who have the
AMOS computer system.
•
Don’t miss the feature
story in this month’s
Iowa Medicine, which
discusses changes to
Iowa’s organ donation
laws and Iowa laws on
living wills and durable
power of attorney for
health care.
Practice Management Workshops for You
Quality in the Medical Office
Wed., Sept. 6 Sioux City
Wed., Sept. 20 IMS headquarters
Wed., Sept. 27 Burlington Medical Center
This course examines trends in quality including
outcome measures and practice parameters.
For more information or to register for any IMS prac-
tice management workshop, call Mary Reinsmoen or
Sherry Johnson at IMS Sendees, 515/223-2816 or
800/728-5398.
IMS Services staff will present
any of our practice management
seminars to individual clinics and
physician offices for a discounted
price. Call Mary Reinsmoen at
IMS Services for more informa-
tion.
Iowa Medicine Volume 85/7 July 1 995 281
Iowa [Medicine
Newsmakers
AT A GLANCE
A partnership between
the UI Health Science
Center, Iowa City, and
St. Petersburg Medical
Academy of Post-gradu-
ate Studies in Russia will
bring U.S. style of family
practice medicine to Rus-
sian physicians. A two-
year program will train
future Russisan teachers
in the principles and
practice of family medi-
cine. Five Russian physi-
cians will spend six
months training in the
U.S. at the UI Department
of Family Practice.
•
At the May meeting of the
Iowa State Board of
Health, Iowa’s new state
epidemiologist, Dr. Patty
Quinlisk, reported on an
outbreak of Legion-
naire’s disease in
Burlington. Three cases
were identified; two
guests and one employee
of a local hotel. The CDC
investigation found no
physical evidence of bac-
teria present at the hotel.
Awards, appointments, etc.
Dr. Ross Madden, Dubuque, was recently
named Internist of the Year by the Iowa Clinical
Society of Internal Medicine. This award was
given to Dr. Madden who demonstrated out-
standing service to community, academia and
state/national medical organizations. Dr.
Patricia McGuire, Cedar Rapids pediatrician,
has been appointed by Governor Branstad to
the Iowa Council on Early Intervention. Dr.
McGuire will serve on the council for two years.
Dr. Jack Spevak, retired Des Moines pediatri-
cian, received an honorary Doctor of Science
degree at Grand View College commencement
exercises for his “generous sharing of self, pur-
suit of knowledge and skill and service to
humanity through pediatric medicine.” Dr. Jill
Hunt has joined Finley Hospital’s ER/Trauma
Department in Dubuque. Dr. George York,
Clinton family practitioner for 35 years, re-
ceived the Mount St. Clare College Award at
recent commencement exercises. Dr. York was
cited for his distinguished service to the com-
munity. Dr. John Viner, internist and infectious
disease specialist at Dubuque Internal Medcine,
recently received the Laureate Award of the
Iowa Chapter of the American College of Phy-
sicians. Dr. R. Bruce Bedell, medical director
of Care Choices HMO, Sioux City, has been
named a diplomate of the American Board of
Medical Management, the national certifying
agency for physician executives. Dr. IanKoontz
has begun practice with Dubuque Internal Medi-
cine.
New members
Algona
William Parker, MD, family Practice
Ames
Steven Sheldahl, MD, family practice
Ankeny
Nancy Alvins, DO, family practice
Boone
David Kermode, DO, general surgery
Cedar Rapids
David Bittleman, MD, internal medicine
Alvina Driscoll, MD, obstetrics/gynecology
Jill Flory, MD, resident
Karen Ilarmon, MD, resident
Kirk Kilburg, MD, resident
Wieslaw Machnowski, MD, pediatric gastroen-
terology
Donald Marquardt, MD, family practice
Daniel McGrail, MD. internal medicine
Steven Paulsrud, DO, resident
Mary Pruzinsky, MD, otolaryngology/head &
neck surgery
Douglas Purdy, MD, internal medicine
William Renk, MD, pediatric adolescent medi-
cine
Stephen Runde, MD, family practice
Jana Serbousek, MD, resident
Gregory Skopec, MD, obstetrics/gynecology
Ronald Weiehert, MD, resident
Timothy Winters, MD, resident
Clinton
Lane Williams, MD, obstetrics/gynecology
Justice Gondwe, MD, internal medicine &
infectious diseases
Corning
Bethel Kopp, MD. internal medicine
Davenport
Steven Aguilar, Ml), resident
Janice Baker, DO, anesthesiology
William Benevento, MD, ophthalmology
Brenda Brown, MD, resident
Shobha Chitneni, MD, internal medicine
William Davidson, MD, gastroenterology
Shane Kasner, MD, resident
Jill Kimm, MD, neurology
Joanne Miller, MD, resident
Michael Phelps, MD, general surgery
Janet Ryan, MD, resident
Benjamin Van Raalte, MD, plastic & hand
surgery
282 Iowa Medicine Volume 85/7 July 1 995
CURRENT ISSUES
Decorah
Gregory McAnulty, MD, family practice
Des Moines
I Laurie Ballew, DO, resident
Wayne Belling, DO, family practice
Douglas Brenton, MD. neurology
James Coggi, MD, pediatrics
Steven Dawson, MD, pediatrics
' Victoria Dietz, MD, resident
Dominic Frecentese, MD, radiology
Samuel Gardner, DO, resident
Ben Gaumer, DO, family practice
Joel Gordon, MD, resident
Ross Huffman, DO, resident
Lori Lynner, MD, resident
[ Celeste Miller, MD, resident
I Kirk Peterson, MD, resident
Timothy Raleigh, DO, resident
Chaudri Rasool. DO, resident
Thomas Reinbold, DO, resident
James Seabert, MD. family practice
Romeo Smith, MD, resident
Dale Steinmetz, MD, resident
Amanda Troutman, DO, resident
William Watson, DO, resident
Mark Weber, MD, resident
Robert Williams, MD, medical oncology
Dubuque
Barry Blyton, MD, radiation oncology
Joseph Compton, MD, internal medicine
Laurie Ganns, MD, neurology
David Houlihan, MD, psychiatry
Margaret Mulderig, MD, physical medicine &
rehabilitation
John Stecker, MD, psychiatry
Grant Westenfelder, MD, infectious diseases
Fort Dodge
John Edeen, MD, orthopedics
Iowa City
David Boysen, MD, dermatology
Timothy Gibbons, MD, orthopedics
Scott Graham, MD, otolaryngology
Robert Keleh, MD, pediatric endocrinology
Karen Maves, MD, internal medicine
Nina Mayr, MD, radiation therapy
John Mehegan, MD, cardiology
Brian O'Meara, MD, gastroenterology
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Iowa Medicine Volume 85 / 7 Julv 1995 283
Iowa | Medicine
FEATURE ARTICLE
Death , dying and
Iowa Law
When has enough medical care been given and when should
nature be left to take its course? As medical science and
technology have advanced, what is in the best interests of
the patient is not always easily ascertained. This article reviews
Iowa law relating to end-of-life issues.
Becky Roorda
Ms. Roorda is manager
of public affiars at the
IMS and has been
involved in legislative
affairs for 15 years.
Physicians face death and dying more
directly than the rest of us. Your professional
lives revolve around helping your patients to
stay or get well and to comfort those whose
lives are ending.
The impending death of my 93-vear-old
grandmother brought home these issues to
me last year. After a long life of doing things
for herself it was difficult for my grandmother
herself and my uncle, who lived down the hill
from her all his adult life, to face the fact that
since 24-hour in home nursing care was not
feasible on her isolated northwest Missouri
farm, the next best option was a nursing
home in Prairie City, Iowa, a few miles from
my parents’ farm.
After moving to the nursing home, her
disease was diagnosed. Active treatment
would likely have done more harm than good
so she continued to live in the nursing home.
Eventually she stopped eating
much, developed pneumonia and
was hospitalized, apparently
unconscious. The family faced the
decision of whether to provide
nutrition through a stomach tube.
I was in the hospital visiting
when the surgeon came in to talk
to my mother about the options
(my uncle had gone home with
the flu). I was impressed with how simply and
clearly he outlined the pros and cons of
providing artificial nutrition and explained
the discussions of the hospital’s ethics
committee. lie made it clear the decision was
up to the family but there were risks involved
with surgical insertion of the feeding tube.
She wasn’t going to get better. He was
compassionate but didn’t mince words.
Time stopped and my brain seemed to
shut off while he was talking. Even with the
absolute clarity of his words my conscious
mind simply didn’t want to comprehend the
message. Even though my grandmother, tiny
in her hospital bed, her breath rattling from
pneumonia, was not the same active person
she had been in my childhood when she
shooed us all outside to play, and even
though she was 93 and her death was not
unexpected, it was difficult to accept.
Later, after the doctor had
answered our questions and left
the room, it seemed the same
thing had happened to my mother.
By reconstructing the doctor’s
clear and simple statements we
understood that what he was
telling us was that my
grandmother was dying. We had
the choice of letting it happen
Even with the
absolute clarity of
his words, my
conscious mind
didn’t want to
comprehend the
message.
284 Iowa Medicine Volume 85 / 7 July 1995
here’s to your
A patient’s guide to better health
Provided by the Iowa Medical Society
Organ &
Tissue
Donation
Who can become a donor?
Everyone should consider himself or herself a potential
organ and tissue donor. Anyone over the age of 18 can
indicate their desire to be an organ donor by signing a
donor card or expressing their wishes to family members.
Relatives can also donate a deceased family member’s
organs and tissues, even those family members under the
age of 18.
Donor Card
This is a legal document under the Uniform Anatomical Gift
Act or similar laws, signed by the donor and the following two
witnesses in the presence of each other.
Donor’s signature
Donor’s date of birth
City & State
Witness
Witness
Next of kin
Telephone
Please type or print full name of donor
In the hope that I may help others, I hereby make this gift for
the purpose of transplant, medical study or education, to
take effect upon my death.
I give: □ Any needed organ/tissues
I I Only the following organs/tissues
Specify the organ(sytissue(s)
Limitations or speoial wishes if any
Donation of heart, liver, lung, pancreas or heart/lung can
occur only in the case of brain death. Brain death occurs
when a person has an irreversible, catastrophic brain
injury which causes all brain activity to stop perma-
nently. Donation of tissues such as bone, skin or corneas
can occur regardless of age and in almost any cause of
death. Your medical condition at the time of death will
determine what organs and tissues can be donated.
How do I become a donor candidate?
Fill out a donor card and carry it with you in your wallet
or purse. A sample card (front and back) appears at left.
Actual cards may also be obtained through the Iowa
Statewide Organ Procurement Organization (call 1/800-
831-4131) or your local driver’s license station.
Most states have a way you can use your driver’s license
to indicate your desire to be a donor. In Iowa, a box
appears in the right hand bottom comer on the front side
of the license. In that box you may indicate a “Y” to
donate your organs or tissues.
It is also extremely important that you let your family
know you want to become a donor at the time of your
death. Ask family members to sign your donor card as
witnesses. When you die, your next of kin will be asked to
give their consent for you to become a donor. It is very
Insert to Iowa Medicine, July 1995
important they know you want to be a donor because that
will make it easier for them to follow through on your
wishes. It would also be useful to tell your family physi-
cian, religious leader and attorney about your wishes.
You may also want to indicate in your will that you wish
Organs and Tissues to be ^ organ/tissue donor.
for Transplantation
Corneas _
Middle Ear
Lung
Heart
Blood Vessels
Liver
Pancreas
Kidneys
Bone
Bone Marrow -
Skin
What If I change my mind about donating my
organs or tissues?
If you change your mind, tear up your donor card. If you
indicated your willingness to donate on your driver’s
license, cross out that section on your license. Be sure to
let your family know of your decision.
Are there religious objections to organ/tlssue
donation?
Most major religious groups in the U. S. approve and
support the principles and practices of organ/tissue do-
nation. Transplantation is consistent with the life
preserving traditions of these faiths. However, if you have
any doubts, you should discuss them with your spiritual
leader.
Will the quality of hospital treatment and efforts
to save my life be lessened If staff know I am
willing to be a donor?
No. A transplant team does not become involved until
other physicians involved in the patient’s care have
determined that all possible efforts to save the patient’s
life have failed.
Does organ donation leave the body disfigured?
No. The recovery of organs and tissues is conducted in an
operating room under the direction of qualified surgeons
and neither disfigures the body nor changes the way it
looks in a casket. A traditional, open casket funeral
service can still take place even though many organs and
tissues have been donated.
Is It permissible to sell human organs?
No. The National Organ Transplant Act prohibits the sale
of human organs. Violators are subject to fines and
imprisonment. Among the reasons for this rule is the
concern of Congress that buying and selling of organs
might lead to inequitable access to donor organs with the
2 wealthy having an unfair advantage.
What are the steps Involved In organ donation
and transplantation?
1. A potential donor who has been diagnosed as brain
dead must be identified.
2. Next of kin must be informed of the opportunity to
donate their relatives’ organs and tissues and must
give their permission.
3. An Organ Procurement Organization is contacted to
help determine organ acceptability, obtain the family’s
permission and match the donor with the most appro-
priate recipient(s).
4. Organ(s) and tissue(s) are surgically removed from
the donor.
5. The donor organs and tissues are taken to the trans-
plant center(s) where the surgery will be performed.
When a potential organ donor is identified by hospital
staff and brain death is imminent or present, an organ
procurement organization (OPO) is contacted. The OPO
is consulted about donor acceptability and often asked to
counsel with families to seek consent for donation. If
consent is given, a search is made for the most appropri-
ate recipient(s) using a computerized listing of transplant
candidates managed by the United Network for Organ
Sharing which operates the National Organ Procurement
and Transplantation Network.
It is increasingly common for donors and donor families
to contribute multiple organs and/tissues. Therefore,
several recipients may be helped by a single donor. When
a match is found, the OPO will arrange for the donated
organ(s) to be surgically removed, preserved and trans-
ported to the appropriate transplant center(s). A poten-
tial recipient(s) is also alerted to the availability of an
organ and asked to travel to the transplant center where
he or she is prepared for surgery. The recipient’s diseased
or failing organ is removed and the donated organ is
implanted.
How are recipients matched to donor organs?
Persons waiting for transplants are listed at the trans-
plant center where they plan to have surgery and on a
national computerized waiting list of potential transplant
patients in the U.S. When donor organs become avail-
Did You Know?
•There are 129 lowans wait-
ing for a kidney transplant
•There were 163 kidney
transplants performed in
Iowa in 1994
•There are 12 lowans waiting
for a liver transplant
•There were 39 liver trans-
plants performed in Iowa in
1994
• Nationally, almost 25% of all
individuals awaiting liver
transplants are 10 years old
or younger
•The number of transplanta-
tions has nearly doubled
since 1983, due primarily to
dramatic increases in the
number of individuals await-
ing transplants
• Nationally, there are 39,693
individuals needing trans-
plants— 16,708 females,
22,985 males
able, several factors are taken into consideration in
identifying the best matched recipient(s). These include
medical compatibility of the donor and potential
recipient(s) on such characteristics as blood type, weight
and age; urgency of need; length of time on the waiting list
and distance from the donor site to the recipient trans-
plant center. Usually donors from Iowa get transplanted
into Iowa recipients here first because timing is a critical
element in the organ procurement process. If a suitable
recipient for a particular organ cannot be found in Iowa
the organ is offered out to the rest of our region. If there
is no suitable recipient in our region the organ is offered
nationally. Hearts can be preserved for up to six hours,
livers up to 24 hours and kidneys for 72 hours. Lungs
cannot be preserved outside the body for any extended
period of time.
Transplant teams consisting of ethicists, social workers,
nurses, procurement personnel and physicians alike are
always re-evaluating the methods which aid in the deter-
mination of organ allocation.
This Information on organ/tlssue donation
and transplantation has been provided by
the Iowa Statewide Organ Procurement Or-
ganization. As a service to IMS member
physicians, this Insert may be photocopied
for placement in clinic reception areas. Origi-
nal Inserts may be purchased from the Iowa
Medical Society for 15 cents each. Call
Jane Nleland or Bev Corron at the IMS, 515/
223-1401 or 800/747-3070.
Why should minorities be particularly concerned
about organ donation?
Minorities suffer end-stage renal disease (ESRD), a seri-
ous and life-threatening kidney disease, much more
frequently than do whites. Asian Americans are three
times more likely than whites to develop ESRD; Hispan-
ics are three times as likely and blacks are twice as likely
as whites to develop ESRD.
As with any transplant procedure, it is very important to
assure a close match between donor and recipient blood
type and genetic make-up. Members of different racial
and ethnic groups are usually more genetically similar to
members of their own group than they are to others. (For
example, blacks are usually more genetically similar to
other blacks than they are to whites.) It is important,
therefore, to increase the minority donor pool so good
matches can be made as frequently as possible for minor-
ity patients.
4
FEATURE ARTICLE
naturally fairly soon or prolonging it for
awhile. After discussing it with my uncle who
had early on favored life prolonging
measures, my mother and he both agreed
that the kindest thing, and what my
grandmother probably would have wanted,
was to let her go. She died in the hospice a
week later.
What is the message in this? No surprise
to most physicians, this decision-making
process worked well because the choices
were clear and there were family members
available who could agree on the best course
of action and the desires of my grandmother.
When this is not the case — and even
sometimes when it is — assistance may be
needed. Legal instruments in the form of
living wills and durable powers of attorney
for health care are recognized in Iowa
through the efforts of the Iowa Medical
Society working with the Iowa Hospital
Association and the Iowa State Bar
Association. These documents provide a
legally recognized way to provide advance
guidance to family members, friends and
physicians when the individual is no longer
able to make health care decisions.
Iowa’s Uniform Anatomical Gift Act allows
an individual to make a decision to donate
tissues and organs, relieving family members
of the decision at an emotional time.
Life-Sustaining Procedures Act
Iowa’s Life-sustaining Procedures Act was
passed in 1985 as an initiative of the Iowa
Medical Society and other groups. The Act
provides that a competent adult may execute
a living will and provides procedures for
doing so.
A living will is a document that directs
that life-sustaining procedures be withheld or
withdrawn if the individual’s condition is
terminal and the individual is unable to make
treatment decisions. A living will is not
legally binding if these conditions are not
met. Determination that the condition of the
individual is terminal must be made by two
physicians with that determination recorded
in the medical record.
The living will must be signed by the
individual or a person acting on behalf of the
individual at the individual’s direction, must
be dated and must be either witnessed by
two adults who are not health care providers
(or employees) of the individuals or
notarized.
It is the responsiblity of the individual to
provide the attending physician or other
health care provider with a copy of the living
will. The physician may presume that the
delaration complies with the law and is valid
unless actually notified to the contrary. A
living will may be revoked at any time either
orally or in writing.
Legal issues
A living will is a legally binding document.
If the patient is unable to make decisions and
a living will is in existence, physicians and
other health care providers are required to
follow the terms of the document. Physicians
who are unwilling to participate in the
withholding or withdrawing of life-sustaining
procedures are not required to do so.
However, they are required to take
reasonable steps to transfer the patient to
another physician if the patient has a living
will or if in the absence of a living will a
determination is made by one of the listed
decisionmakers following the procedures
outlined in the law.
Immunities
The law specifically provides that
physicians, persons acting under a
physician’s direction and hospitals are not
subject to civil or criminal liability or guilty
of unprofessional conduct for acting in
accordance with the Life-sustaining
Procedures Act unless actually notified of the
revocation of a living will. Compliance with
continued
Want more
information?
For brochures about Iowa’s
advance directives inclu-
ding living will and durable
power of attorney for
health care, call Bev
Corron at the Iowa Medical
Society.
For single copies of forms
for living wills and durable
power of attorney for
health care, patients
should send a stamped,
self-addressed envelope to:
Iowa State Bar Association,
521 E. Locust, Des Moines,
IA 50309.
For more information on
organ donation, including
organ donor cards, call the
Iowa Statewide Organ
Procurement Organization,
800/831-4131.
Iowa Medicine Volume 85/7 July 1 995 285
Iowa | Medicine
FEATURE ARTICLE
continued
What about legal
immunities?
Physicians, hospitals,
physician assistants,
technicians, enucleators,
medical examiners and
others who comply or
attempt to comply with the
Uniform Anatomical Gift
Act in good faith or with
another applicable state
law are immune from civil
or criminal liability which
might result from making
or accepting an anatomical
gift. An individual who
makes such a gift or the
estate is not liable for any
injury or damages that may
result from the donation if
made in good faith.
the Act is an absolute defense if civil or
criminal liability is asserted.
Durable Power of Attorney for Health Care
A durable power of attorney for health
care is another form of advance directive
legally recognized in Iowa. A durable power
of attorney for health care authorizes an
individual, the “principal”, to designate
another individual, the “attorney in fact”, to
make health care decisions for the principal
when the principal is unable to do so.
Requirements
An attorney in fact may make health care
decisions only if explicitly authorized by the
durable power of attorney for health care, the
durable power of attorney for health care is
dated and correctly witnessed or notarized,
and the attorney in fact is not a health care
provider attending the principal or an
employee of the health care provider. The
attorney in fact may be any other person
designated to make decisions, such as a
trusted friend or relative.
The attorney in fact has priority over all
other individuals in making health care
decisions for the principal if the principal is
unable to make those decisions, including the
decision to withhold or withdraw health care.
The attorney in fact has a duty to act in
accordance with the desires of the principal
as expressed in the document or otherwise
made known.
If the desires are unknown the attorney in
fact has a duty to act in the best interests of
the principal, considering the principal’s
overall medical condition and prognosis.
Revocation
Like a living will, a durable power of
attorney for health care may be revoked at
any time and in any manner without regard
to the mental or physical condition of the
principal. The revocation is in effect for a
health care provider only when the health
care provider is notified. Documentation of
the revocation should go in the medical
record.
Immunities
As with a living will, a health care
provider is not subject to criminal
prosecution, civil liability or professional
disciplinary action for acting in good faith. A
health care provider is not required to
participate in the withholding or
withdrawing of health care necessary to keep
the principal alive but the attorney in fact
may transfer the responsiblity for the care of
the principal to another health care provider.
An attorney in fact is similarly protected for
decisions made in good faith.
Iowa’s advance directive laws are designed
to provide a way for a patient to deal with
health care decisions, including the issue of
life-sustaining care, in advance. Physicians
are encouraged to discuss these issues with
patients while they are able to make
decisions.
This is simply a brief overview of Iowa’s
laws relating to advance directives and organ
donation and should not be considered legal
advice. Physicians may wish to consult with
legal counsel when dealing with specific
cases.
Uniform Anatomical Gift Act
Iowa’s Uniform Anatomical Gift Act was
adopted in 1971 to provide a legally
recognized way for individuals to make a
decision in advance to donate bodily organs.
In 1994, the Iowa Statewide Organ
Procurement Organization (ISOPO)
approached the IMS with a draft of a new
version to update the law to recognize the
many changes in the field of organ
transplantation that have occurred since
then. The IMS, the Iowa Hospital Association
286 Iowa Medicine Volume 85/7 July 1 995
FEATURE ARTICLE
and the Iowa State Bar Association all
worked with ISOPO to review and refine the
draft legislation. The result was Senate File
117 which went into effect July 1, 1995.
Who may donate
Any competent individual who is at least
18 years old may donate an organ. The new
law also allows a minor at least 14 years old
to make the decision to donate with the
written consent of a parent or legal guardian.
Such individuals may also legally make the
decision not to donate. If an individual has
not made a decision not to donate, the
following individuals may donate organs or
tissues on behalf of the decedent in order of
precedence: the attorney in fact pursuant to
a durable power of attorney for health care,
the decedent’s spouse, an adult child, a
parent, an adult sibling, a grandparent or a
guardian at the time of death.
How to donate
An individual may make an organ
donation by signing a “document of gift”
which may be a specific donor card, a
uniform donor card, a will or any other
written document executed to meet the
provisions of the law. Indication on a driver’s
license of the desire to donate is also
recognized as expressing the individual’s
intent; prior to enactment of the new law the
driver’s license designation had no legal
meaning. The document of gift may indicate
that the individual wishes to donate the
whole body or only specified body parts. The
document of gift may be changed or revoked
by the individual donor at anytime before
death. A valid document of gift executed by
the donor may not be revoked by any other
person.
Who may receive
An individual may designate any of the
following as the donee:
1. A hospital, physician, organ pro-
curement organization, or bank or storage
organization for transplantation, therapy,
medical or dental education, research, or
advancement of medical or dental science.
2. An accredited medical or dental
school, college, or university for education,
research, or the advancement of medical or
dental science.
An anatomical gift may also be made
without designating a donee, in which case
any of the listed entities may accept the gift.
What should be done with the document of gift
The law allows an individual to keep the
document of gift or to deliver the document
to the designated donee. It is also recom-
mended that copies be made available to
persons who may need to know about them
such as close family members or an attorney
in fact if a durable power of attorney for
health care has been executed. A document
of gift or a copy may be deposited in any
hospital, organ procurement organization
band or storage organization, or registry
office that accepts the document of gift for
safekeeping. Upon the death of the donor
the entity in possession of the document
may allow the hospital or physician to
examine or copy the document to include in
the records.
Examination
The body part may be examined or tested
for HIV or communicable diseases to ensure
medical acceptability of the gift.
Autopsy
The body may be autopsied pursuant to
other state laws.
What if there is no
advance directive?
If a person has no living will
or other form of advance
directive, the law provides
that life-sustaining
procedures may be
withheld or withdrawn from
a patient who is in a
terminal condition and who
is comatose, incompetent
or otherwise physically or
mentally incapable of
communication. To do so,
there must be agreement
between the attending
physicians and one of the
following in order of
priority:
1. The attorney in fact
designated to make
treatment decisions for the
patient
2. A court-appointed
guardian if one has been
appointed
3. Spouse
4. Adult child {or a majority
of adult children)
5. A parent
6. An adult sibling
Iowa Medicine Volume 85/7 July 1 995 287
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
Iowa | Medicine
SCIENCE AND EDUCATION
The Journal
of the Iowa Medical Society
Latex allergy
# RKAgarwal, MD; A Al-Shash, MD
A 28-year-old dentist had eczema of both
hands which got better after he discontinued
wearing latex gloves. He occasionally coughed
and sneezed in the office. He underwent an
appendectomy under spinal anesthesia hut
developed unexplained profound hypotension
within 10 minutes of the abdominal incision.
Evaluation post-operatively showed him to
have IgE antibodies to latex proteins.
This case history demonstrates the emerg-
ing problem of IgE sensitization to latex.
Over the last five years, the FDA has received
over 1,100 reports of injury and 15 deaths
associated with latex allergy. This is not to be
confused with Type IV hypersensitivity (con-
tact dermatitis) to rubber.
Type I reactions
Natural rubber (Cis-1,4 polyisoprene) is a
processed plant product, derived from the
milky sap of the plant called Ilevea Brasilien-
sis. The type I reactions occur in response to
protein allergens which surround the cis-1,4
polyisoprene particles while type IV hyper-
sensitivity occurs to rubber additives like
mercaptobenzothiazole, tetramethvlthiauram
and other chemicals which serve as accelera-
tors and antioxidants. Most patients with
type IV hypersensitivity do not have type I or
IgE mediated allergic reactions. It is possible
to have type I hypersensitivity without asso-
ciated type IV hypersensitivity. There is
some evidence that continued use of natural
rubber or latex product in patients with aller-
gic contact eczema to latex might increase
the likelihood of developing IgE sensitization.
Route of exposure
Immediate hypersensitivity reactions have
been elicited by exposure to rubber gloves,
condoms, barium enema or bladder
catheters, balloons, toys, dental prophylaxis
cups and sports equipment. Gloves are of
major importance because of their frequent
use. A person could be exposed to the aller-
gen via skin; oral, vaginal, rectal or uretheral
mucosa; or parentral routes depending on the
circumstances.
Exposure of skin and respiratory tract usu-
ally causes only local symptoms (i.e., hives,
conjunctivitis and rhinitis, swelling of the lip,
tongue and throat) and if the allergen is
inhaled into the lung, it might cause symp-
toms of bronchospasm. Occasionally, severe
systemic reactions can occur even after just
being in the operating room or the dentist’s
office. Some reactions result from irritation
of repeated hand washing and need to be dif-
ferentiated from latex hypersensitivity.
Direct mucosal and parenteral exposure
pose the greatest risk of anaphylaxis. Patients
who usually experience mild or manageable
cutaneous (contact urticaria) or respiratory
reactions are known to develop anaphylaxis
after mucosal or parenteral exposure.
All latex related deaths reported to FDA
have been associated with mucosal expo-
sure to latex-containing barium catheter.
Fortunately, these have been withdrawn
from the market.
Risk groups
Most latex allergy occurs in persons sharing
one thing in common: repeated exposure to
latex. Persons at risk include health care work-
ers, rubber industry workers and children with
spina bifida and urogenital abnormalities. Any-
one who is exposed to rubber or latex products
repeatedly can expect to be sensitized.
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for July
1995.
RK Agarwal, MD
A Al-Shash, MD
The authors practice
with the Allergy > Institute,
P. C. in West Des Moines.
Iowa Medicine Volume 85 / 7 July 1995 289
Iowa j Medicine
Latex allergy
continued
The prevalence of latex allergy in the gen-
eral population is unknown, but it is higher
among atopies (those with asthma, allergic
rhinitis or atopic dermatitis). Five to 10% of
health care workers have evidence of IgE sen-
sitization. The risk is higher among surgeons,
dentists, operating room nurses and laborato-
ry technicians who have to wear gloves for a
longer period of time than other health care
workers. The prevalence of IgE mediated sen-
sitization in children with spina bifida varies
from nine to 28%.
Diagnosis
All symptoms related to rubber product
use may not be related to latex. For example,
condom dermatitis may be related to spermi-
cidal jellies, creams and foams, diaphragms
and lubricants. Frequent handwashing with
various soaps, detergents or disinfectant solu-
tions can produce either an irritant or an
allergic contact dermatitis.
RAST (radio-allergosorbent), “use test”
and epicutaneous skin tests are used to con-
firm the diagnosis. For most patients with
spina bifida, in vitro tests are adequately sen-
sitive. For health care workers and others
with latex allergy, RAST test has been consid-
erably less sensitive. A negative RAST test in
these subjects cannot exclude latex allergy.
There is some evidence that epicutaneous
skin tests are more sensitive than the RAST.
For the most part, prick skin tests are safe,
but there are reports of patients developing
anaphylaxis following skin testing. However,
there are no reported fatalities following skin
testing. For extremely sensitive patients, one
can order a RAST test. If the RAST is nega-
tive, one can proceed with use test. If the use
test is also negative, skin test with diluted
latex allergen and test the person with
increasing concentration of the latex allergen.
Prevention
Avoidance of latex products is the only
way to eliminate the problem, but this is diffi-
cult as many household and medical devices
contain latex products.
Health care workers with contact urticaria
or contact eczema will do fine if they avoid
latex gloves. The problem is harder to resolve
if they experience ocular, respiratory or sys-
temic symptoms as everyone who works j
around them needs to switch to non-latex j
gloves. A partial solution to this problem is to
use non-powdered gloves as their use results
in less aerosolization of the latex particles.
Even if these patients become symptom- \
free after latex avoidance, they must be j
warned of the potential risk of anaphylaxis
when these patients or health care workers j|
undergo surgical procedures which expose j
them to latex from a variety of sources. Some ij
patients are so sensitive that a small amount
of allergen in the rubber ports for IV medica-
tions/fluids or medicine vials can induce ana-
phylaxis. It is important that the medical |
charts of all patients be labeled as latex aller- j
gic. It might be useful to give the patient a i
medic alert bracelet. We give all our patients
a list of non-latex alternatives.
Premedication with steroids, H, and H,
antagonist and ephedrine, has been tried to
prevent latex-induced reactions prior to
major, surgical and dental procedures, but
failures have been reported. It cannot be used
as an alternative to allergen avoidance, but
can be considered to decrease the severity of
an accidental exposure to latex. \
Note: Contact the editors of Iowa Medi- i
cine for a list of latex-free alternatives for
use in hospitals. El
290 Iowa Medicine Volume 85 / 7 July 1995
Thyrotoxic periodic paralysis
# John DiBaise, MD
After a one week history of progressive
muscle weakness, a 22-year-old Chinese
graduate student was unable to walk. He was
taking no medications, there was no family
history of a neuromuscular disorder and his
only other complaint was heat intolerance.
The physical examination was remarkable for
tachycardia, a grade HAT systolic ejection
murmur at the left lower sternal border,
severe proximal muscle weakness in all
extremities and diminished deep tendon
reflexes in the legs.
Laboratory analysis revealed a serum
potassium of 1.7 mEq/L, phosphorous of 0.8
mEq/dL, glucose of 152 mg/dL and a normal
creatine phosphokinase (CPK). After admin-
istration of intravenous potassium phosphate
the potassium and phosphorous levels nor-
malized and the muscle weakness resolved.
Thyroid function studies revealed a free T4 of
4.3 mcg/dL (0. 5-2.1) and TSII <0.1 mlU/L
(0. 4-5.0). Electromyography was normal and
a 24-hour radioactive iodine uptake was 82%.
While periodic paralysis was described in
the late 19th century, the association
between hyperthyroidism and periodic paral-
ysis was not apparent until the early 1900s.12
Thyrotoxic periodic paralysis (TPP) occurs
predominantly in Asian populations and is
seen in approximately 2% of Japanese and
Chinese who develop thyrotoxicosis. It is rare
in other ethnic groups and occurs in only
0.2% of North Americans with thyrotoxico-
sis. Most cases occur in the second to fifth
decade and there is a male preponderance
(13:1).
Familial periodic paralysis (FPP) and TPP
both involve recurrent attacks of flaccid
weakness that usually begin in the legs and
there may be a prodrome of muscle cramps
and/or stiffness. Attacks are not usually asso-
ciated with cognitive or sensory deficits and
the bulbar musculature and muscles of respi-
ration are usually spared. Serious atrial and
ventricular arrhythmias and respiratory fail-
ure have also been described.3 In Orientals
hyperthyroid symptoms usually predate TPP
by months to years.4 Recovery of muscle
function occurs in reverse order of the
appearance of paralysis. Moderate exercise
will attenuate the severity of the attack and
may hasten the recovery.5 Numerous trigger-
ing factors have been described, including
carbohydrate load, vigorous exercise then
rest, cold, trauma, infection, menses, alcohol
and emotional stress. Ingestion of high carbo-
hydrate foods and vigorous exercise followed
by rest commonly precede a hypokalemic
attack.5
The principal biochemical abnormality in
TPP is hypokalemia but total body potassium
stores remain normal.6 Serum phosphorous
levels may be depressed and CPK levels are
variably increased. Electromyograms and
muscle biopsies reveal nonspecific changes
characteristic of a myopathy.
Treatment
Spontaneous recovery within three to 36
hours is the rule. Oral potassium chloride is
the treatment of choice as intravenous
administration of dextrose-containing solu-
tions may delay the correction of serum
potassium and may be associated with hyper-
kalemia. Potassium exits muscle tissue at a
rate of approximately 15 mEq/hour during
the recovery phase of an acute attack.7
Administration of phosphate is generally not
necessary as levels normalize simultaneously
with potassium levels.
Management of the underlying hyperthy-
John DiBaise, MD
Dr DiBaise practices with
the University of Iowa
Depart ment of Internal
Medicine.
Iowa Medicine Volume 85 / 7 July 1995 291
Iowa I Medicine
SCIENCE AND EDUCATION
Thyrotoxic periodic paralysis
continued
roidism is the definitive treatment and until a
euthyroid state is achieved, persons with TPP
should avoid potential triggering events. Propra-
nolol, potassium chloride and spironolactone
have been used with limited success as prophy-
lactic agents. After effective treatment of hyper-
thyroidism persons with TPP will no longer
develop spontaneous or induced attacks.
Pathophysiology
TPP usually occurs in conjunction with
Graves’ disease but has also been reported
with multinodular goiter, solitary thyroid
adenoma, lymphocytic thyroiditis, iodine-
induced thyrotoxicosis and thyroid hormone
ingestion. No consistent genetic marker has
been identified but an underlying genetic
basis is suggested by family studies and the
ethnic distribution.
An electrophysiologic abnormality of the
skeletal muscle membrane is suspected but
the precise nature of the pathophysiologic
disturbance in TPP remains undefined.8 Grob
has hypothesized that the intracellular shift
of potassium into muscle results in hyperpo-
larization of the muscle membrane with a
resultant muscle refractoriness.9 Insulin may
also play a role in potassium shifts. Some
individuals with TPP have an exaggerated
insulin response to a carbohydrate load and
markedly elevated insulin levels have been
observed in some persons with TPP during
attacks. 10,11 Insulin may act to increase the
activity of Na + -K + -ATPase causing an
increase in intracellular potassium.
The exact role of thyroid hormone in TPP
is uncertain. Elevated thyroid hormone levels
alter plasma membrane permeability to sodi-
um and potassium, a function linked to
increased Na+-K+ pump activity.12 Hyperthy-
roidism also increases tissue responsiveness
to beta-adrenergic stimulation which in turn
may increase Na+-K+ pump activity.13 In TPP,
thyroid hormone may work in concert with
increased insulin and beta-adrenergic activity
to alter resting membrane potentials that
lead to muscle paralysis. 14,15
References
References noted in this article are avail-
able from either the author or the editors of
Iowa Medicine. El
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'owa [Medicine
THE EDITOR COMMENTS
Are you afraid
of death?
There is no cure for birth and death save
to enjoy the interval.
George Santayana, Philosopher, 1863-1952
We begin to die at birth; the end flows from
the beginning.
Marcus Manilius, Latin poet, First century BC
I will use that regimen which, according
to my ability and judgement, shall be for
the welfare of the sick, and I will refrain
\from that which shall be baneful or inju-
rious.
Oath of Hippocrates
the beginning.” As Santayana concluded,
“There is no cure for birth and death save to
enjoy the interval.”
In a recent issue oiJAMA (April 5, 1995, p.
1039) McCue discusses the naturalness of death .
He declares that the acceptance of death di-
rectly conflicts with the medications and
legalization that characterizes modern society’s
treatment of dying elderly patients. In years
past before the technology and pharmaceutical
regimens of today death was considered natu-
ral and expected. The caring physician stayed
with the family during the last hours assisting in
the understanding of this natural event. Our
profession today has become so defensive about
death that we view this last chapter of life as a
medical failure and defeat.
McCue suggests making dying a diagnosis
wherein the physician recognizes
it as a chronic, incurable disease.
Acceptance then negates fruitless
attempts at diagnosis and cure-
more consultations, drugs and
technological procedures which
only delay the inevitable. All this
at additional cost in stress and
suffering; yes, also in dollars; to all
involved. However, when death is imminent it
is not for physicians to terminate life by any
methods of euthanasia. Life is sacred. Its
beginning with birth proceeds to death by what-
ever pathway is set for each one. Let us view it
as natural and inevitable and celebrate each life
as a wonderful existence for however long it
may be. [EH
Most physicians, as most people, are fear-
ful of death. We physicians have learned
to equate death with professional defeat
or failure. Our lot has been to keep the dying
patient alive by whatever means available, of-
ten when it is obvious such measures may be
futile. Yet, there is the fear of defeat, the actual
fear of death and the fear of legal
reprisal when there has not been a
total effort to keep the dying pa-
tient alive a bit longer.
Our Oath of Hippocrates de-
clares that we as physicians will
“use that regimen which according
to our ability and judgement shall
be for the welfare of the sick.” This
declaration does not imply that extraordinary
means, though futile, be indicated. The only
addition to this declaration is that we shall
“refrain from using means that are baneful and
injurious.”
Life consists of three phases — birth, living
and death. As Manilius declared centuries ago,
“We begin to die at birth; and the end flows from
We physicians
have learned
to equate
death with
professional
defeat or failure.
Marion Alberts, MD
Iowa Medicine Volume 85/ 7 July 1995 2 93
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▼
1995 IMS House of D
The 1995 annual meeting of the Iowa Medical Society House
of Delegates was held April 29-30 at the Des Moines Marriott
Hotel. House sessions were chaired by Donald Kahle, MD,
speaker. The annual banquet was held April 29 and was
emceed by James White, MD, IMS president.
▼
House of Delegates policy actions
Reports considered by the 1995 House of Delegates came
from the Reference Committee on Medical Service and
Miscellaneous Business, the Reference Committee on
Legislation and the Reference Committee on Reports of
Officers and Articles of Incorporation and Bylaws. Based on
consideration of the reports, the IMS will take the following
actions:
•Reaffirm the IMS Statement of Principles.
•Increase 1996 IMS dues by #10.
•Maintain the current quality and format of Iowa Medicine,
while recognizing that the Board has a fiduciary responsibil-
ity. Approved an amendment to the Bylaws striking the
requirement that Iowa Medicine be published on a monthly
basis and a resolution that the Board consider an Iowa
Medicine subscription fee for non dues-paying members
(emeritus and life members).
•Approve an amendment to the Bylaws providing for repre-
sentation of Iowa medical specialty societies in the House of
Delegates and the addition of a new section establishing cer-
tain eligibility requirements and an approval process.
•Approve an amendment to the Bylaws providing that the
executive vice president shall be covered by the indemnifi-
cation provisions.
•Continue to hold the annual meeting of the IMS House of
Delegates in April.
•Make state specialty societies aware of IMS capability to
provide administrative services on a fee-for-service basis.
•Establish a task force to work with other organizations on
appropriate revisions of Iowa law relating to HIV/AIDS.
Support physician and public education about HIV/AIDS,
available preventive measures and legislative revisions to
permit patient-specific information to reach the appropriate
state health agencies.
•Oppose the use of the Drug Enforcement Administration
(DEA) registration number for any purpose other than for
verification to the dispenser that the prescriber is authorized
by federal law to prescribe controlled substances. Encourage
physicians to report any inappropriate requests for DEA
numbers to the Iowa Board of Pharmacy Examiners and edu-
cate physicians on the reporting process.
•Continue to support the AMA’s policy statement on firearm
safety and regulation.
•Referred a resolution regarding pleas in criminal cases.
•IMS Task Force on Domestic Violence be continued and
actively participate in legislative studies relating to domestic
violence with other organizations as opportunities arise.
•Establish a Task Force on Violence Intervention and
ELEGATES PROCEEDINGS
Prevention to investigate and recommend methods to assist
in keeping “unsupervised weapons” out of the hands of
minors.
•Adopt a prudent layperson definition of emergency ser-
vices.
•Develop a support program for physicians being sued for
malpractice and include educational materials to assist local
physician organizations. Work with liability insurance carri-
ers and appropriate IMS committees to develop such a sup-
port program.
•Encourage physicians to place their assets in plans which
are protected from civil liability awards including malprac-
tice suits and that physicians be encouraged to work with
pension planners to ensure pension assets are protected.
•Encourage the AMA Council on Ethical and Judicial Affairs
to continue to review the ethical issues relating to appropri-
ate care at the end of life and work with other organizations
on educational strategies for end-of-life issues.
•Reaffirm its policy to strongly encourage the IFMC to pro-
vide the House of Delegates an annual report to increase
communications between the two organizations.
•Adopt a 3-page IMS policy statement on CHMIS (see June
1995 issue of Iowa Medicine for full text).
•Support AMA efforts to eliminate entirely or develop more
fairly calculated Geographic Practice Cost Indices.
•Referred a resolution regarding the start of the school day.
•Encourage students and residents to be involved in the leg-
islative and political process.
T
Award winners
At the annual banquet, Laveme Wintermeyer, MD, former
state epidemiologist from Des Moines, received the 1995 IMS
Merit Award. Dr. Herman Hein, Iowa City, received the Ben
T. Whitaker Award of the Interstate Postgraduate Medical
Association of North America. Dr. Paul Laube, suigeon from
Dubuque, received the IMS Physician Community Service
Award. The John H. Sanford Award was given to Jim Koch,
executive secretary of the Rock Island and Scott County
Medical Societies. Mary Ann Bechler, clinic administrator
for the Northwest Iowa Orthopaedic and Sports Center in
Sioux City received the IMS Outstanding Medical Office
Administrator Award and members of the IMS Alliance were
recipients of the Washington Freeman Peck Award.
T
April 29 session
Registered for the April 29 session of the House were 133
physician delegates. Minutes of the 1994 House of Delegates
session were approved as summarized in the July, 1994 issue
of Iowa Medicine.
New delegates to the House were introduced and reference
committee appointments were announced.
Dr. Richard Corlin, vice speaker of the AMA House of
Delegates, addressed the House and information regarding
▼
1 9 9 5 IMS House of Del
CINTINBEI
the House agenda was reviewed.
Two checks totaling over #18,800 were presented on behalf
of the AMA-Education and Research Foundation to Dr.
Robert Kelch, dean, University of Iowa College of Medicine.
The funds, raised primarily through the efforts of the IMS
Alliance, are to be utilized by the U of I College of Medicine’s
excellence fund and assistance fund.
T
Reports to the House
Reports contained in the 1995 House of Delegates handbook
were approved.
Supplemental reports from the Board of Trustees, Judicial
Council and two committees were referred to reference com-
mittees. The physicians’ memorial list was presented by Dr.
Kathryn Ophiem, chairman of the IMS Judicial Council, with
delegates observing a moment of silence in honor of
deceased physicians.
Informational reports were submitted by the IMS Education
Fund, IMS Services and MMIC. Dr. James White presented
his address as outgoing IMS president, emphasizing the need
to minimize the effect of governmental regulations on the
practice of medicine.
IMS OFFICERS FOR 1995-96
The report of the Nominating Committee was read. The fol-
lowing officers were elected:
President-elect
Vice president
Trustee (3-year term)
Speaker, House of
Delegates
Vice speaker
AMA delegates
(2-year term)
William McMillan, MD, Ottumwa
Sterling Laaveg, MD, Mason City
Siroos Shirazi, MD, Iowa City
Donald Kahle, MD, Dubuque
Tom Throckmorton, MD, Spencer
Clarkson Kelly, Jr, MD, Charles City
Daniel Youngblade, MD, Sioux City
AMA alternate delegates Bernard Fallon, MD, Iowa City
(2-year term) Bryan Pechous, MD, Dubuque
Four District Councilors were also chosen. They are: Robert
Kent, MD, Burlington (District I); John Justin, MD, Mason
City (District VI); Jay Heitzman, MD, Ottumwa (District IX);
and Linda Iler, MD, Lake City (District XIII).
Sixteen resolutions submitted by councilor districts were
introduced and referred to reference committees. Actions
taken on the resolutions are reported subsequently.
The speaker presented information on the Reference
Committee hearings and the concluding session of the IMS
House of Delegates.
T
Life members
The following physicians were elected to life membership in
the Iowa Medical Society. (Life members are physicians who
have practiced medicine for 50 years and have been mem-
EGATES PROCEEDINGS
bers of the IMS for 15 consecutive years):
Robert Allen, MD, Burlington; William Baird, MD, Ames;
Elmer Bean, MD, Council Bluffs; James Coffey, MD,
Emmetsburg; Eugene Coffman, MD, Bellevue; Russell
Conkling, MD, Cedar Rapids; Dean Cooper, MD, Fort
Dodge; Thomas Coriden, MD, Sioux City; Richard Corton,
MD, Waterloo; Robert Donlin, MD, Harlan; Harley Feldick,
MD, Iowa City; Frederick Fuerste, MD, Dubuque; Louis
Greco, MD, Boone; Charles Gutenkauf, MD, Des Moines;
John Huey, MD, Cedar Rapids; Robert Jongewaard, MD,
Wesley; James Kennedy, MD, Coralville; Walter Kopsa, MD,
Tipton; Otto Kruse, MD, Tipton; Rufus Kruse, MD,
Marshalltown; Jean Le Poidevin, MD, Waterloo; Edward
Mason, MD, Iowa City; Emmett Mathiasen, MD, Council
Bluffs; Roger Mattice, MD, Emmetsburg; Theodore Mazur,
MD, Burlington; Richard Miller, MD, Waterloo; Robert
Morrison, MD, Waterloo; Jack Moyers, MD, Iowa City;
Gerald Nemmers, MD, Washington; Don Newland, MD, Des
Moines; Loran Parker, MD, Des Moines; Gordon Rahn, MD,
Mt. Vemon; John Singer, MD, Iowa City; Glenn Skallerup,
MD, Red Oak; William Spencer, MD, Osage; Warren
Swayze, MD, Muscatine; Joel Teigland, MD, Des Moines;
John Thomsen, MD, Armstrong; Russell Van Wetzinga, MD,
Bettendorf; Donald Wagner, MD, Sioux City, Janet Wilcox,
MD, Iowa City; and Grey Woodman, MD, Clinton.
Emeritus IMS membership was accorded to 55 physicians.
▼
April 30 session
Registered for the April 30 session of the House were 103 del-
egates. Minutes of the April 29 session were read and
approved.
Mrs. Barbara Bell, past president of the Iowa Medical Society
Alliance, addressed the delegates regarding Alliance projects
during the past year. Mrs. Sandra Mitchell, president-elect of
the American Medical Association Alliance, also addressed
the House.
The House of Delegates acted on reports from three refer-
ence committees and the speaker acknowledged the efforts
of the committees. The House was adjourned and Joseph
Hall, MD of Des Moines was installed as president for the
coming year.
Organizational meetings of the IMS Board of Trustees and
Judicial Council occurred following Dr. Hall’s installation.
[ovva [Medicine
THE ART OF MEDICINE
What’s in a name?
My regular readers might recall that I
occasionally voice my interest in words
and meanings. I suppose I’ve always
had some degree of interest or curiosity about
them, but as I’ve grown older I feel ever more
urgently the power for good or ill of those
abstract symbols we call words. The Hebrew
Bible (Genesis, Chap. 11:1-9) tells the wonder-
ful story of the tower of Babel, which as a child
1 always found interesting and picturesque.
Even in biblical times there was recognition of
the enormous (and therefore theologically
threatening) power if everyone “spoke the same
language”; thus arose the “justification” for
multiple languages and the associated disper-
sion of groups of people.
Often we hear people dismiss disagreements
about words as “just semantics”.
Just? Another uncritical maneu-
ver is to ask the question, “What’s
in a name?” to imply that names
make no difference. One should
always remember the source and
purpose of that question. It’s a
wonderfully persuasive, seductive
line that Shakespeare assigned to
Romeo’s use in convincing Juliet that his family
name, Montague, hated by her Capulet family,
need not impede their romance. Unfortunately
for them and so many others, hatred often runs
thicker than love. Or consider the great num-
ber of requests tallied each year by the Ameri-
can Library Association to remove Huckle-
berry Finn from school or public libraries be-
cause Mark Twain names his major character
“Nigger Jim” and today the adjective has grown
painful and pejorative. If your doctor says, “We
finally have a diagnosis: cancer of the pan-
creas,” are you likely to respond, “Oh well, one
diagnosis is as good or bad as another”? A
patient whom I met recently while visiting the
Gillis W. Long Hansen’s Disease Center at
Carville, Louisiana (formerly called our na-
tional leprosarium ) described the anguish and
dreadful consequences in his own life and that
of his family caused by the use of the words
“leper” and “leprosy”. A worldwide effort is
underway to change the terminology to Hansen’s
Disease.
These reflections about words and meanings
have been prompted by a card that just came
from the Iowa Medical Society, cautioning the
reader, if “about to sign a managed
care contract”, to consider a list of
contract pitfalls. Crucial phrases
include “hold harmless clause”,
“due process rights”, “non-compet-
ing covenants”, “evergreen clause”.
The final question, “How and how
much will you be paid?” has nice
familiar one-syllable words that
convey an idea I can grasp easily; those other
phrases are pitfalls indeed. As the message
suggests, an appropriate translator (often called
an attorney) is indeed someone “you may wish
to consult”. Words may convey delight — even
ecstasy — but never let yourself fall prey to the
childhood shibboleth which claims that while
sticks and stones may break my bones, words
will never hurt me. QjH
A worldwide
effort is under-
way to change
the terminology
to Hansen’s
Disease.
Richard Caplax, MD
Iowa Medicine Volume 85/ 7 July 1995 295
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314/726-3009 (IMs welcome).
J
296 Iowa Medicine Volume 85/ 7 July 1995
CLASSIFIED ADVERTISING
LeMars, Iowa
Seeking quality physicians to prac-
tice at a 4300 average volume ER.
Director and staff positions. Full
and regular part-time. Democratic
group, highly competitive compen-
sation, paid St. Paul malpractice with
unlimited tail, excellent benefit pack-
age/bonuses to full-time physicians.
ACUTE CARE , INC., P.O. Box 515,
Ankeny, Iowa 50021; phone 800/
729-7813.
Stoughton, Wisconsin — Dean Medical Center,
a 350-physician multispecialty group is
actively recruiting a BE/BC family physician
for our Stoughton Clinic, which is located
approximately 20 miles south of Madison
fpopulation 190,000). Currently there are 3
internists, 4 family practice physicians, one
i pediatrician and one general surgeon at this
clinic. Call would be shared equally among
the family physicians. The Stoughton Hospital
is a 50-bed facility adjoining the new medical
office building. Stoughton has a population of
approximately 9,000 and growing with
excellent schools and neighborhoods. This is
an excellent position which enables you to live
in a safe community with the cultural and
professional resources of a larger city just
minutes away. A two-year guaranteed salary
plus incentive and benefits is being offered for
this position. Contact Scott Lindblom, Dean
Medical Center, 1808 West Beltline Highway,
Madison, Wisconsin; 1-800/279-9966; 608/250-
1550 (work); 608/833-7985 (home); or fax
608/250-1441.
Emergency Medicine
Administrative Opportunity
Ottumwa, Iowa
Exceptional opportunity for primary care
trained or experienced emergency physician.
• 19,000 Annual Volume
• 12-Hour Shifts
• Double Coverage
• New Department
1 • Flexible Scheduling
• No Call Responsibility
• Generous Compensation Package
• Paid Malpractice Insurance
• Health/Dental, Life, Disability
Send CV or call Sheila Jorgensen
EMERGENCY PRACTICE ASSOCIATES
PO Box 1260, Waterloo, Iowa 50704
800/458-5003 or fax 319/236-3644
Washington, Iowa — Washington County
Hospital is seeking a director for its emergency
department. Board certification in either
family practice or internal medicine with at
least 2 years emergency department experi-
ence is required for this position. Hours are
from 6 p.m. — 6 a.m. Monday through
Thursday with no on-call. Guaranteed income
of approximately $100,000 with benefits
available to include life, health, dental and
401K Plan. In addition, Coastal has the ability
to procure professional liability on your behalf.
Please call Paula Martin at Coastal Physician
Services of the Midwest, Inc. at 1-800/326-
2782 for more information, or fax your CV to
314/291-5152.
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
of Des Moines. We have a beautiful new
facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-malting, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
Emergency Medicine — Outstanding opportuni-
ties in emergency medicine available in a
variety of Iowa and Minnesota locations for
primary care trained or experienced emer-
gency physician. Quality lifestyles in family
oriented communities. Guaranteed compensa-
tion, paid malpractice, health/dental, life,
disability. Send CV or call Sheila Jorgensen.
Emergency Practice Associates, P.O. Box
1260, Waterloo, Iowa 50704; 800/458-5003,
fax 319/236-3644.
Time For a Move?— BC/BE FP, IM, OB/GYN,
PEDS Our promise — We’ll save you valuable
time by calling every hospital, group and ad in
your desired market. You’ll know every job
within 20 days. We track every community in
the country, including over 2000 rural
locations. Cedar Rapids, Des Moines, Quad
Cities, Kansas City, Boston, Chicago, India-
napolis, many more. New openings daily — call
now for details! The Curare Group, Inc., M-F
9am-8pm, Sat 1-5 pm EST. 800/880-2028, Fax
812/331-0659.
ACUTE CARE
ANESTHESIA SERVICES, L.C
Recruiting MD/DO Anesthesiologists & CRNAs
Professionally rewarding, equitable
anesthesia practices.
Full-time and part-time.
Iowa and Nebraska.
Incentive-based compensation & benefits —
including St. Paul medical professional
liability insurance.
Contact Melissa J. Milliken, CMSC,
Director of Professional Relations
800/729-781 3 or send CV to
PO Box 515, Ankeny, Iowa 50021
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for $2.00
per line with a S30 minimum per insertion.
For members of the Iowa Medical Society
the rate is $20 per insertion. Display
classified advertising sells for $25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85/ 7 July 1995 297
Iowa [Medicine
CLASSIFIED flDVERTISI N C
Boone , Iowa
Seeking a quality emergency physician
interested in a stellar emergency medi-
cine practice. Full and regular part-
time position available. Democratic
group, paid St. Paul malpractice with
unlimited tail. Excellent benefit pack-
age/bonuses to full-time physicians.
Average volume with above-average
compensation. ACUTE CARE, INC.,
P.O. Box 515, Ankeny, Iowa 50021;
phone 800/729-7813.
115-Physician, Midwest Multispecialty —
Seeking BG/BE candidates: dermatology,
family medicine, pulmonology. Comprehen-
sive health care center for 14 counties,
population over 320,000. Two-year guaran-
teed salary, relocation and CME funds part of
the many benefits. Safe, thriving family
community with stable economy offers a
rewarding quality of life. Purdue University
offers academics, cultural events and Big 10
sports. Physician Recruitment, Arnett Clinic,
PO Box 5545, Lafayette, Indiana 47904; 800/
899-8448.
STORM LAKE, IOWA
Rural lakeside community provides unique
setting for self-styled family practice. Em-
ployment with clinic foundation owned by
county hospital means no buy-ins, 1:9 call
coverage with weekend ER relief coverage,
full employment contract with guarantee
and excellent benefit package. You deter-
mine what patients to hand off in an outpa-
tient hospital based referral system of 25
specialists. A+ schools, A+ recreation and
A+ amenities. Send CV or call Darrell
Pritchard, Administrator, Buena Vista
Clinic, Box 742, Storm Lake, Iowa 50588;
collect 712/732-5012; fax 712/732-2538.
Family Practitioner • Internist
Want the best of
worlds?
Live and work in a rural community-yet have easy
access to the educational, cultural, shopping, and en-
tertainment opportunities of the big city. Enjoy all the
benefits that go with small-town living-good neigh-
bors, safe schools, affordable housing, abundant rec-
reational choices-and go to the city when you want!
St. Croix Falls, Wisconsin is located just over the
scenic St. Croix River from Taylors Falls, Minnesota and
within 45 minutes of the metropolitan Twin Cities. With
25,000 households within the clinic service area, River
Valley Medical Center is the region’s largest and most
diversified practice group-13 family practitioners, 2
internists, 2 general surgeons, 2 orthopedic surgeons
and a physician assistant. Clinic is attached to a 50-
bed acute care hospital with a wide range of services.
Guaranteed first -year salary with second-year part-
nership and excellent fringes.
m
Send detailed CV to:
Cathy Kortas
River Valley Medical Center
208 S. Adams St.
St. Croix Falls, Wl 54024
Physicians & Surgeons
needed for
locum tenens and
permanent opportunities
nationwide
For more information contact:
Physician Search Consultants
101 27th Avenue SE, Suite 120
Minneapolis, Minnesota 55414
612/627-9350 or 800/345-9350
Family Practitioner — Fairfield, Iowa. Board
certified/board eligible to join 1 of 2 busy
successful clinics located next to hospital.
Fairfield is the county seat with a rural
population of 10,000. A university town,
situated in the tree covered hills of southeast
Iowa. There are 3 state parks within 30 miles.
Fairfield’s schools rank among the best in
Iowa. Call/write Walter Brownlee, CEO,
Jefferson County Hospital, PO Box 588,
Fairfield, Iowa 52556; 515/472-4111.
298 Iowa Medicine
Volume 85/7 July 1 995
Happy
Anniversary
Ruth !!
40 Years9
Service
To Iowa
Physicians! !
And, Goiny
Strong!!
In 1955 Ruth Clare’s name was brand new
to Iowa physicians.
That’s changed dramatically over 40 years.
Now, in 1995, Ruth’s name is well known to
Iowa Medical Society members and their
staffs.
We’re proud to salute Ruth on the fortieth
anniversary of her employment, first with
The Prouty Company, and now with its suc-
cessor, Bernie Lowe & Associates, Inc.
To many Iowa doctors and clinic managers,
Ruth is a cordial voice on the telephone or
a signature at the bottom of an informative
letter. On other occasions, she’s a pleasant
face across the table in your office or ours —
explaining how a particular IMS-sponsored
insurance program works.
Ruth continues to represent BLA ably. She’s
real life testimony to our commitment of
service to Iowa physicians.
Please join us in congratulating Ruth on her
long and excellent performance. She and all
of us at Bernie Lowe & Associates are proud
of our long association with the Iowa
Medical Society.
Call us when we can help with your per-
sonal insurance needs — or those of your
practice.
BERNIE LDWE & ASSOCIATES. INC.
Insurance Administrators to Professional Associations £*
Universities and Colleges
515-222-0011 1-B00-942-471B FAX 515-222-0915
2700 Westown Parkway. 5uite 410
West Oes Moines. Iowa 50255-1411
IowajMedicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrey, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Vcljko K. Zivkovich, MI)
Robert A. Colman, MD
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Robert J. Barry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease ,
Cancer and Surgery of Sk in
Fort Dodge Medical Center, PC
Carey A. Bligard, MD, I' AAI)
James I). Bunker, Ml), FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Bragc, MD
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical ('arc
Associates, PC
Daniel II. Gcrvich, MD
Daniel J. Schrocdcr, MD
Ravi K. Ycniuri, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MI), ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, M1)
Laurence S. Krain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potential
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgcsc, MD
Loren J. Mouw, MI)
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Hosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
300 Iowa Medicine Volume 85/7 July 1 995
PROFESSIONAL LISTING
Neurosurgical Services LLP
lobcrt i lay nc, MI)
Thomas A. Carlstrom, MD
)avid J. Boarini, MI)
1215 Pleasant, Suite 608
Des Moines 50309
115/241-5760
tobcrt C. Jones, MI)
i, Kandy Winston, MD
Douglas K, Kooutz, MI)
1600 Grand Avenue, Suite 210
pes Moines 50312
1515/283-2217
Neurological Surgery
Chad D. Abcmathey, MI)
1953 1st Avenue SE
jbedar Rapids 52402
119/363-4622
Neurological Surgery
Dbstetrics/Gynecology
Fort Dodge Medical Center, PC
lirian L. Welch, Ml>
[800 Kenyon Road
?ort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, MD
John M. Graethcr, Ml)
Gilbert W. Harris, Ml)
James A. Davison, MD
Vorman F. Woodlicf, MD
Erie W. Bligard, MI)
David I). Saggau, MI)
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert I). Whinerv, MD
Stephen II. Wolken, Ml)
Robert II. Goffstein, MI)
Lyse S. Strnad, MD
John F. Stamler, MD, PhD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
Orthopaedic Surgery
Fort Dodge Mcdieal Center, PL
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MI)
Randall S. Brcnton, MI)
James L. Dummett, MD
Mick E. Vanden Bosch, MI)
3121 4th Street, SAV.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MD
Marshall C. Grciman, MI)
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MI)
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Hill, MD
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Iowa Orthopaedic Center, PC
Marvin II. Duhanskv, MD
Marshall Flapan, MD
Sinesio Misol, MI)
Joshua I). Kimelnian, DO
Timothy G. Kenney, MD
Lynn M. Lindaman, MI)
Jeffrey M. Farbcr, MD
Kyle S. Guiles, MI)
Scott A. Meyer, MD
Cassini M. Igram, MI)
Rodney E. Johnson, MD
Martin S. Rosenfcld, DO
Donna J. Ilahls, MI)
Jill K. Mcilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: $10.00 first
3 lines; S2.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85/ 7 Jidy 1995 301
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MI)
Eugene Peterson, Ml)
Richard B. Merrick, MI)
Peter V. Boesen, Ml)
Robert It. Updcgraff, MI)
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neck
Surgery, PC
Thomas J. Benda, Sr., Ml)
James W. White, MI)
Craig C. Ilerther, MI)
Thomas J. Benda, Jr., MI)
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MI)
Guy E. McFarland, MI)
Thomas F. Viner, Ml)
Douglas E. Dawson, MI)
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Smits, MI), PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Phillip A. Einquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgcsc, MI), FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Perinatology
I)es Moines Perinatal Center, PC
Neil T. Mandsager, Ml)
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level IF)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice I). Sehncll, MD
F'areeduddin Ahmed, MD
Arthur B. Scarle, MD
Bogdan E. Krysztofiak, MD
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MI)
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matvsik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary Diseases
Suigery
Wendell Downing, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
F4>rt Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Rehabilitation Medicine Associates
William I). dcGravelles, Jr., MI)
Charles F. Dcnhart, MI)
Marvin M. Hurd, MD
William C. Koenig, Jr., Ml)
Karen Kicnker, Ml)
Todd C. Troll, Ml)
Lori A. Sapp, MI)
Younkcr Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Advertising Index
Bemie Lowe & Associates 299
Blue Cross Blue Shield 288
Dale Clark Prosthetics 266
Heartland Health System 280
IMGMA 303
IMPAC 275
IMS Services 294
Josephs 270
Medical Records
Assistance Services 283
Medical Management
Strategies, PC 280, 292
MMIC 304
Principal Health Care 272
River Valley Medical Center 298
U.S. Air Force 294
U.S. Army Reserve 280
r
302 Iowa Medicine Volume 85/7 July 1 995
ovval Medicine THE PRESIDENT COMMENTS
Principles of
Medicare reform
Reform of Medicare will be a priority dur-
ing the coming year. At the AMA Annual
Meeting, Speaker of the House Newt
Gingrich made a satellite presentation. The
key issues will be making multiple choices
available such as medical savings accounts,
i/oucher system, a fee-for-service and continu-
ation of the current system. I believe this will
oe our best opportunity to affect real changes in
.Medicare. To balance the federal budget, the
debate must be shifted from provider cuts to
Medicare reform. Physicians account for 23%
af the Medicare dollars and have absorbed 32%
of Medicare cuts over the last decade. This
poses a real threat to access.
The AMA believes reform must incorporate
five basic principles:
1. Beneficiary cost conscious-
ness must be encouraged. It may
be necessary to ask those who
have the ability to pay higher
premiums to do so. “Medigap”
insurance insulates many benefi-
ciaries from the cost of medical
services.
2. Price competition among
physicians and providers must be facilitated to
increase economic efficiency. Mechanisms that
allow beneficiaries to participate in their health
care decisions on the basis of service, quality
and price should be established.
3. Intergenerational inequity and financing
must be reduced. Four workers support each
beneficiary; however, this falls to two workers
by the middle of the next century. The working
population cannot be expected to pay higher
taxes.
4. Dependence of future generations on
Medicare must be reduced. Incentives should
be created for more people to become finan-
cially independent of Medicare during
retirement.
5. Regulatory and administrative complex-
ity must be curtailed.
The most rapidly growing components of
Medicare Part B are payments to outpatient
hospital facilities, independent laboratories and
home health services. The Medicare popula-
tion is growing faster than the general
population.
Since 1967, the number of enrollees has
increased from 19.5 to 35.2 mil-
lion. By 2030 it’s projected
approximately 20% of the U.S.
population will be over 65.
Technological progress in medi-
cine has been a significant factor
increasing the cost of Medicare.
The increased rate of use with
more expensive consumption of
expanded benefits increased the
amount paid per enrollee by 1,340% when
compared to the inception of the program in
1966.
It is no wonder that benefit payments of §4.7
billion in 1967 have increased to Si 59 billion
in 1994.
The dialogue is just beginning. This time it’s
possible that ideas physicians have espoused
since 1986 may be heard. El
The debate
must be
shifted from
provider cuts
to Medicare
financing reform.
Joseph Hall, MD
Iowa Medicine Volume 85 / 8 August 1995 311
Happy
Anniversary
Rath!!
40 Years’
Service
To Iowa
Physicians! !
And. Goiny
Strony!!
In 1955 Ruth Clare’s name was brand new
to Iowa physicians.
That’s changed dramatically over 40 years.
Now, in 1995, Ruth’s name is well known to
Iowa Medical Society members and their
staffs.
We’re proud to salute Ruth on the fortieth
anniversary of her employment, first with
The Prouty Company, and now with its suc-
cessor, Bernie Lowe & Associates, Inc.
To many Iowa doctors and clinic managers,
Ruth is a cordial voice on the telephone or
a signature at the bottom of an informative
letter. On other occasions, she’s a pleasant
face across the table in your office or ours —
explaining how a particular IMS-sponsored
insurance program works.
Ruth continues to represent BLA ably. She’s
real life testimony to our commitment of
service to Iowa physicians.
Please join us in congratulating Ruth on her
long and excellent performance. She and all
of us at Bernie Lowe & Associates are proud
of our long association with the Iowa
Medical Society.
Call us when we can help with your per-
sonal insurance needs — or those of your
practice.
BERNIE LBWE 6c ASSOCIATES. INC.
Insurance Administrators to Professional Associations &
Universities and Colleges
515-BBB-BB11 1-BBB-94B-471B FAX 515-BBB-B915
B7BB Westown Parkway, Suite 41B
West Bes Moines. Iowa 5UB66-1411
GUEST EDITORIAL
owa [Medicine
Organized medicine:
it’s for students, too
Having recently completed a six-week sum-
mer internship at the Iowa Medical Soci-
ety, I have a message to share with other
students on the importance of organized medi-
cine. As you go through medical school, you
,vill probably hear little from the medical school
acuity about organized medicine and its im-
portance to your future as a doctor. This is an
unfortunate consequence of the sheer amount
of material medical students are expected to
absorb and the fact that there is not time to
nclude more information in the curriculum.
In the real world, medicine is coming under
che increasing control of governmental agen-
cies and private insurance companies. It is vital
:hat doctors understand the issues that fall
autside the realm of clinical medicine and into
chat of “organized medicine”.
What is organized medicine?
Put simply, it is the affiliation of
physicians into professional orga-
nizations that act as advocates for
and provide assistance to doctors
pn a variety of topics from medical
liability reform to Medicare reim-
pursements. The American Medi-
cal Association (AMA) is the largest and most
prominent professional organization for doc-
tors. The AMA is part of what is called the
‘Federation of Medicine” that includes state
medical societies and scores of county and
ocal societies. The AMA and the IMS offer and
encourage membership in the Medical Student
Section (MSS) to medical students, alleopathic
md osteopathic alike.
When you will soon be tearing your hair out
over the Krebs cycle in biochemistry, why
should you join the Medical Student Section of
the AMA or IMS? It is understandable that
medical students would want to not be both-
ered by economic and political matters when
they are trying to learn medicine, but no matter
how altruistic your motives for becoming a
doctor, medicine and the control of patient
care is increasingly being taken from physi-
cians and given to government and private
insurance companies. Physicians are being
paid less for the work they do, and, more
importantly, must justify their treatment deci-
sions to non-medical professionals. When doc-
tors are forced to consider the bottom line over
patient well-being, the doctor-patient relation-
ship is compromised.
Becoming involved in organized
medicine through membership in
the Medical Student Section of the
AMA and the IMS is one additional
way to insure the highest quality
of health care for our patients.
The membership fee is less than
the cost of many medical text-
books and there are many benefits.
The competition to get into medical school is
as tough as it has ever been and your presence
in the first year class is a testament of your
commitment to academic excellence. Your
participation in organized medicine will help
assure that the commitment you have already
made for a rewarding career helping patients
will be realized. Qul
The member-
ship fee is
less than
the cost of
many medical
textbooks.
Eric Stone, M2
Eric Stone is a second year
medical student at the U of
I College of Medicine. He is
a native of Ames. For in-
formation on joining the
Medical Student Section of
the IMS, call Sandy Nelson
at 800/747-3070.
Iowa Medicine Volume 85 / 8 August 1995 313
Iowa I Medicine
IMS Update
CURRENT ISSUES
AT A GLANCE
Regina Benjamin , MD,
MBA is the first physician
elected to the American
Medical Associatimi
Board of Trustees “young
physician member” post.
Dr. Benjamin, the only
practicing physician in
Bayou LaBatre, Ala-
bama, was named ABC
News “Person of the
Week”; Time Magazine
called Iter one of Amer-
ica’s 50 future leaders
under the age of 40.
•
Women’s Health ’95, a
one-day conference, will
be held Friday, Sept-
ember 15 at Drake
University’s Olmstead
Center. Keynote speak-
ers will address a num-
ber of women’s health
issues. The conference is
cosponsored by the
University of Iowa;
physicians attending
will earn AMA Category >
1 credits. For more
information, call Drake
University, 515/288-
4543 or fax 515/288-
4745.
IMS to participate in national conference
The Iowa Medical Society has been asked
to participate in a national conference on
violence prevention. Sponsored by the
Centers for Disease Control, “Bridging
Science and Program” will be held October
22-25 at the Des Moines Convention Center.
The conference will be organized around
four tracks: family/domestic violence, youth
violence, suicide and workplace violence.
The IMS has been asked to do a presentation
on domestic violence. Staff at the University
of Iowa Injury Prevention and Research
Center will work with members of the IMS
Task Force on Domestic Violence regarding
the Society’s portion of the program.
The conference is funded by a grant
obtained for Iowa by Senator Tom Harkin. It
will be open to members of any profession
interested in violence issues. Conference
organizers say Vice President A1 Gore and
Focus on IMS Alliance
On June 18-21, I was privileged to attend the
AMA Alliance Annual Meeting in Chicago. Listening
to Dr. Robert McAfee (immediate past president of
the AMA) was inspiring, but the statistics on family
violence are truly astounding. During the last two
weeks, at least one patient in your spouse’s office
was a victim of family violence. Who was it?
Family violence is categorized under four head-
ings: child physical abuse, child sexual abuse,
spouse abuse and elder abuse. We in the IMSA are
committed to decreasing this explosion of violence
in our communities. Won’t you and your spouse join
us? The IMSA is involved in educational programs to
help us change this behavior and we would welcome
your help. We all lead busy lives, but if this epidem-
ic is to be brought under control, we have to start at
home. Please join me, the IMS Alliance and the Iowa
Medical Society in helping educate lowans about
family violence.
For more information on joining the Alliance, call
me or Sandy Nichols at 800/747-3070.
Contributed by Linda Miller, president, IMSA
possibly Mrs. Clinton will attend some por-
tion of the program.
Watch future issues of Iowa Medicine for
further details about this conference.
AMA condemns medical patenting
The patenting of medical procedures may
increase the cost of treatment and thus limit
patient access to the procedures, says the
AMA’s Council on Ethical and .Judicial Affairs.
“Since the time of Hippocrates, physicians
have relied on the open exchange of informa-
tion without expectation of financial reward
for advancing medical science,” said John
Glasson, MD, chair of CEJA. Du]
Specl\lty Society Update
We welcome the Iowa Association of Pathologists,
which has joined 10 other specialty societies
receiving staff support from IMS Services. The IAP
is one of an increasing number of specialty soci-
eties finding their member officers have insufficient
time to fulfill the responsibilities of their associa-
tion. If you belong to an association interested in
discussing staff services, contact Dana Petrowsky,
manager, specialty services, 800/728-5398.
The IMGMA Fall Meeting will be September 13-15
at Lake Okoboji. The theme is “Winning through
Teamwork”. There will be a panel discussion of
new directions in physician-hospital partnerships
led by Steve Brenton, president of the Iowa
Hospital Association.
The Iowa Psychiatric Society and the Mental
Health Advocacy Coalition are planning a special
event to take place during Mental Illness
Awareness Week October 5. The theme — “The
Benefit of Benefits” — involves parity of mental
health benefits under insurance coverage.
The Iowa Vascular Surgery Society held its Spring
Meeting July 14-15 in Davenport.
In a recent Iowa Medicine, Dr. Jeffrey Watters was
incorrectly listed as newly-elected president of the
American Academy of Otolaryngology. Dr. Watters
is president of the American College of Radiology,
Iowa Chapter.
314 Iowa Medicine Volume 85 / 8 August 1995
Iowa | Medicine
CURRENT ISSUES
Futures
Medicare under a microscope at AMA Ganske speaks out on Medicare
The AMA unveiled its “Medi-Choice” plan
to reform Medicare at a press conference dur-
ing the AMA 1995 House of Delegates in
Chicago. The AMA’s plan would change the
system from one which guarantees set bene-
fits to one that guarantees contributions and
lets beneficiaries decide how to spend them.
The AMA says its plan — which will feature
a number of different options for Medicare
recipients — will save the federal government
about $162 billion over seven years.
The AMA’s reform ideas are not falling on
deaf ears. During a videocast speech to physi-
cians attending the AMA meeting, Speaker
Newt Gingrich displayed a yellow book con-
taining the AMA’s working draft. Gingrich's
speech featured an anti-government, pro-free
enterprise theme.
Lonnie Bristow, MD, AMA president, said
Congress will never get a grip on costs until
incentives are changed. The AMA believes
the program needs a complete overhaul,
focusing on five points: individual responsi-
bility, correcting the transfer of funds across
generations and among the elderly, cutting
paperwork, using competition to control
costs and reducing unnecessary care.
The best existing program after which the
new Medicare program could be modeled is
the Federal Employees Health Benefit
Program. People who buy a lesser package of
benefits are at risk to pay the remainder if
they need care which is not covered.
The plan would introduce competition
among doctors by eliminating Medicare’s dic-
tated prices. Doctors would post their prices
and patients could choose practitioners.
The AMA believes the plan will remove the
need for Medigap policies which increase uti-
lization.
The AMA also favors raising the eligibility
age for Medicare and income testing to
remove the subsidy for wealthy older
Americans.
According to a recent article in the Des
Moines Register , Rep. Greg Ganske believes
medical savings accounts may be the best
way to check the unsustainable growth in
Medicare. Rep. Ganske, a Des Moines recon-
structive surgeon, distributed a position
paper outlining his views to members of
Congress.
Ganske strongly opposes greater use of
managed care for Medicare beneficiaries, an
idea which some Republicans support. He
believes the idea wouldn’t save money and
could jeopardize the quality of care.
“Unless we make major structural changes
in Medicare, we are merely rearranging deck
chairs on the Titanic,” Ganske commented in
his paper.
Ganske is a member of a House committee
with jurisdiction over a portion of Medicare.
Headed for a clash?
Angry physicians and giant managed
health care companies are headed for a clash,
experts said during a recent debate spon-
sored by the Institute of Medicine in Chicago.
Physicians say the results of the conflict
may be a health care system more personal
than today’s increasingly cold business, but
more efficient than yesterday’s cost-blind pri-
vate practice.
“Managed care is not a destination, but a
journey,” commented Janies Todd, MD, the
AMA’s executive vice president.
The former editor of the New England
Journal of Medicine said there is a “growing
discontent among physicians. During my 50-
year career in medicine, I’ve never seen a
time when doctors are more distressed and
concerned about the future of their profes-
sion.”
The major factor is the rise of HMOs and
continued
AT A GLANCE
Blue Cross Blue Shield
has announced that,
beginning July 1,
Milliman & Robertson’s
Health Care Manage-
ment Guidelines will be
incorporated into uti-
lization management
review criteria. These
practice parameters are
already being used by
other health care orga-
nizations. A review of
the Milliman & Robert-
son practice parameters
will be on the agenda at
a fall meeting of the IMS
Committee on Medical
Service. For more infor-
mation, call Barb Heck
at the IMS, 800/747-
3070 or 515/223-1401,
ext. 6 27.
As of press time, con-
gressional hearings on
the future of Medicare
and Medicaid were
underway once again,
and the AMA is continu-
ing to pursue all appro-
priate opportunities to
present transformation
recommendations.
Iowa Medicine Volume 85 / 8 August 1995 315
Iowa [Medicine
CURRENT ISSUE S
Futures
continued
The purpose of the
summit is to
discuss streamlin-
ing health care
regulation in the
environment of
health care reform.
other companies that have attempted to
apply the bottom-line of business to the art of
medicine, said debaters in Chicago.
Regulatory summit in Newton
Easing the burden of health care regulation
will be the main item on the agenda at an
August 29 “regulatory summit” in Newton.
The IMS participated in a steering committee
which planned the summit.
The purpose of the summit is to bring
together “regulators” and “regulatees” to dis-
cuss coordinating and streamlining health
care regulation in the environment of reform.
Bruce Vladek, director of the Health Care
Financing Administration, will be a guest
speaker.
Watch for a report on the summit in the
September Iowa Medicine.
CHMIS Governing Board update
Patient-specific data and transaction
charges were considered at a recent meeting
of the CHMIS Governing Board.
The Governing Board, which includes Beth
Bruening, MD and Dale Andringa, MD, dis-
cussed the difference between patient data
and patient information. It was pointed out
that the original CHMIS steering committee
did not envision release of patient-specific
data. From the beginning of CHMIS develop-
ment, the IMS has argued against release of
any patient-specific data.
The Governing Board voted to accept the
concept that patient-specific data will not be
released. Exact definitions of “patient-specif-
ic” and “patient identifiable” will be present-
ed at a later meeting.
The Governing Board also discussed the
issue of financing the CHMIS system through a
per-transaction surcharge. The party who ben-
efits the most from electronic processing will
pay the per-transaction surcharge. One inter-
pretation is that payers benefit from claim
submission, preauthorization and remittance
advice; providers benefit from insurance eligi-
bility verification and claim status.
Other updates from the CHMIS Governing
Board meeting include:
•The Quality Advisory Committee has
expressed concern about the quality of data
entered into the CHMIS if the issue of V-
codes is not addressed. The problem is
caused by the fact there are inconsistencies
in how insurance companies pay V-codes.
•Several subcommittees to the Data
Advisory Committee have been appointed to
deal with outpatient pharmacy data elements
to be included from insurance claims, stan-
dard reports to be generated by the CHMIS
data repository and the minimum data set
and process for collecting patient satisfaction
and health status surveys.
•The Board discussed establishing a “copy-
right” to ensure that purchasers of data can-
not resell the data base. However, it was
emphasized that CHMIS has no control over
conclusions that may be drawn from the data.
Outside entities cannot say CHMIS endorses
any report prepared externally.
•The concept of the data repository storing
information in “journals” was discussed. It
was suggested that data in the repository be
matched (insurance claim data with pay-
ments), overriding original information with
resubmitted claims so there is no duplication.
•Networks will be governed by fines; there
will be rules regarding how they can use data
they collect. A network can build its own data
repository if the network obtains proper
authorizations and contracts with providers
they serve. Iowa statutes will protect disclo-
sure of patient-specific data.
•The Request For Proposal (RFP) for the
data repository is expected to be finalized by
the end of August. The Network Certification
Task Force presented their revised criteria to
the full advisory committee in late June.
There are no certified networks at this time;
it will probably be early in 1996 before a net-
work is certified.
•The CHMIS Governing Board will not dis-
cuss details of the cost of funding and operat-
ing the CHMIS until after RFPs are received.
Besides per-transaction charges, the Govern-
ing Board also discussed membership or
license fees as a possible source of funds.
•Dr. Andringa brought up possible prob-
lems providers residing in border communi-
ties may have in meeting CHMIS require-
ments. These providers see many Iowans who
work out-of-state and have insurance with a
company not licensed in Iowa. However,
other Governing Board members said this
should not be a problem since providers will
use their networks to file electronically and
the networks may go to paper claims to sub-
mit to any insurance company not required
to participate in CHMIS. C3
316 Iowa Medicine Volume 85/8 August 1 995
Iowal Medicine
GUEST EDITORIAL
IMS staying involved
in the CHMIS process
July 1, 1996 — the implementation date for
the Community Health Management Infor-
mation System (Cl IMIS) — is less than one
year away and Iowa physicians must be aware
of what they must do to be prepared. Included
with this Iowa Medicine is an educational in-
sert for physicians. This insert was produced
by the Communications and Education Advi-
sory Committee of the Cl IMIS Governing Board.
The CHMIS Governing Board has stated quite
clearly they fully expect CHMIS to be imple-
mented on schedule. Only physicians (MDs
and DOs), hospitals and outpatient pharmacies
will submit data to CHMIS on July 1, 1996.
Other providers such as dentists, chiroprac-
tors, optometrists, etc., will participate during
Phase I after a one-year notice of their expected
implementation date.
The IMS has been instrumental
in shaping the development of
CHMIS. We argued successfully
that electronic insurance eligibil-
ity verification must be available
July 1, 1996. This system should
verify the patient’s insurance and
effective dates, co-pay amounts
and the procedures which require pre-authori-
zation. Up-to-date status on how much of a
patient’s deductible has been met will probably
be added later in Phase I.
It has also been decided that CHMIS will not
release information identifying a patient by
name. Data to conduct longitudinal research
studies which track an individual’s encounters
through the health system will be available, but
never in such a way that would allow a re-
searcher to identify with certainty an
individual’s name, address, social security num-
ber, etc. IMS physicians serving on CHMIS
advisory committees have spoken very effec-
tively on protecting patient confidentiality.
CHMIS will not release provider-specific re-
ports. CHMIS reports will discuss aggregate
data, i.e., most common diagnoses, total health
expenditures, etc. However, this will not pre-
clude any other interested organization from
buying the CHMIS data base, analyzing the data
for their specific purposes, issuing reports and
drawing conclusions from their analysis. This
may include provider-specific data.
Finally, IMS physicians have actively pur-
sued an equitable sharing among all stakehold-
ers of costs necessary to fund
CHMIS. From the outset, the IMS
has argued that the cost of CHMIS
should not increase the expense
to operate a practice.
To finance CHMIS, a surcharge
will be added to all transactions,
in addition to what networks may
charge physicians and payers. The
Governing Board has directed that the party
who benefits most from electronic CHMIS trans-
actions will pay the surcharge.
CHMIS will be here before we know it. Of-
fices already computerized and sending elec-
tronic insurance claims are well-positioned to
meet CHMIS requirements. Offices which are
not computerized will have several options avail-
able to comply with CHMIS. Qu]
They fully
expect
CHMIS
to be
implemented
on schedule.
Terrence Briggs, MD
Dr. Briggs, a Marshall-
town obstetrician, is
chair of the Iowa medical
Society's CHMIS
Committee. Ed Whitver
and Barb Heck, IMS staff,
are available to answer
questions or help you
develop a strategy as July
1, 1996 approaches.
Iowa Medicine Volume 85/8 August 1 995 317
Iowa | Medicine
Legislative Affairs
AT A GLANCE
According to a recent
article in the Des Moines
Business Record, fresh-
man congressman Greg
Ganske, a Des Moines
surgeon and one of 73
incoming freshmen, is
gaining a reputation for
being “thoughtful and
issue-oriented; not a
grandstander. ” The Nat-
ional Journal, a Wash-
ington political maga-
zine, compliments Rep.
Ganske for “showing
spunk” by taking on the
GOP braintrust and for
gaining a seat on the
powerful Commerce
Committee.
•
The fight over how and
when to balance the
budget is “ getting seri-
ous” and could go into
the fall, says the
Kiplinger Newsletter.
The House and Senate
will soon approve a
compromise which
trims spending growth
by SI trillion over the
next seven years, the
newsletter predicts.
Congress may put a dol-
lar limit on Medicare for
future years and fill in
the blanks later.
Votes on key issues by Iowa lawmakers
The June Iowa Medicine carried a review
of 1995 legislative issues of interest to the
IMS. Health-related issues were not at the top
of legislative leaders’ agendas in 1995; conse-
quently there were fewer roll call votes of
interest to the IMS.
On many controversial issues the action
took place in committee with no votes by
either the full Senate or House of Represent-
atives. For example, there were no roll call
votes on the IMS bill to define surgery or on
the any willing provider issue. We may see
more action on some issues in 1996.
Following are the votes on several key
issues. (Votes for IMS position in bold.)
• HF 394 — IMS bill reducing statute of lim-
itations for minors in medical malpractice
cases. (No vote in Senate on this issue.)
HOUSE — Ayes: Arnold, Baker, Bell, Blodgett,
Boddicker, Boggess, Bradley, Branstad, Brauns,
Brunkhorst, Carroll, Churchill, Coon, Corbett,
Connack, Cornelius, Daggett, Disney, Drake, Drees,
Eddie, Ertl, Carman, Gipp, Greig, Greiner, Gries,
Grubbs, Grundberg, Ilahn, Halvorson, Hammitt,
Hanson, Harrison, Heaton, Houser, Huseman, Jacobs,
Klemme, Kremer, Lamberti, Larson, Lord, Main,
Martin, Mascher, May, Mertz, Metcalf, Meyer, Millage,
Mundie, Nelson B., Nutt, O’Brien, Rants, Renken,
Running, Salton, Schulte, Siegrist, Sukup, Teig,
TVirell, Van Fossen, Vande Hoef, Veenstra, Weidman,
Weigel, Welter, Van Maanen.
HOUSE — Nays: Bernau, Burnett, Cataldo, Cohoon,
Connors, Doderer, Harper, Holveck, Hurley, Jochum,
Koenigs, Kreiman, Larkin, McCoy, Moreland, Murphy,
Myers, Nelson L., Ollie, Schrader, Shoultz, Warnstadt,
Wise, Witt. Not voting: Brammer, Brand, Dinkla, Fallon,
Thomson.
• SF 258, requiring setting of fees for copies
of medical records provided to attorneys.
SENATE — Ayes: Bisignano, Black, Boswell, Connolly,
Dearden, Deluhery, Dvorsky, Fink, Flynn, Fraise,
Gettings Giannetto, Gronstal, Halvorson, Hammond,
Hansen, Horn, Husak, Judge, Kibbie, Murphy, Neuhauser,
Palmer, Priebe, Sorensen, Szymoniak, Vilsack.
Nays: Banks. Bartz, Bennett, Boettger. Borlaug,
Douglas, Drake, Freeman. Hedge, Iverson, Jensen,
Kramer, Lind. Lundby, Maddox, McKean, McLaren,
Redfem, Rensink, Rife. Rittmer, Tinsman, Zieman.
HOUSE — No vote in 1995.
• SF 117, Uniform Anatomical Gift Act.
SENATE — Ayes: All except those not voting. Not vot-
ing: Hansen, Judge, Maddox.
1 IOUSE — Ayes: Ml except those not voting. Not vot-
ing: Brammer, Ertl, Hammitt, Hurley.
• SF 118, statewide trauma system.
SENATE (first version) — Ayes: Bartz, Bisignano,
Black, Boettger, Boswell, Connolly, Dearden, Deluhery,
Drake, Dvorsky, Fink, Flynn, Freeman, Gettings,
Giannetto, Gronstal, Hammond, Hansen, Horn, Husak,
Judge, Kibbie, Kramer, Lundby, Maddox, Murphy,
Neuhauser, Palmer, Priebe, Redfem, Rife, Rittmer,
Sorensen, Szymoniak, Tinsman, Vilsack, Zieman.
Nays: Banks, Bennett, Borlaug, Douglas, Halvorson,
Hedge, Jensen, Lind, McKean, McLaren, Rensink.
SENATE (final version as amended by House) — Ayes:
All senators.
HOUSE — Ayes: Ml except as follows. Nay: Meyer.
Not voting: Brammer, Ertl, Rants.
Drug therapy management by pharmacists
The Board of Pharmacy Examiners has
Thank your legislators!
Please thank legislators who voted with us on
these issues. Whether or not your legislators
supported the IMS position, take the oppor-
tunity this summer and fall to get to know
them. Few legislators have a background in
health care; most will appreciate you taking
the time to help them learn more about the
issues. Call Paul Bishop of the Iowa Medical
Society staff, 515/223-1401 or 800/747-
3070, ext. 621 for help in working with leg-
islators.
318 Iowa Medicine Volume 85/8 August 1 995
CURRENT ISSUES
proposed rules to allow pharmacists to pro-
vide drug therapy management under proto-
col or guidelines from a prescribing practi-
tioner (physician, physician assistant, nurse
practitioner, dentist, podiatrist).
According to the proposal, drug therapy
management would include the authority to:
• “Initiate, modify and manage drug thera-
py”;
• “Collect and review patient drug histo-
nes ;
• “Measure and review routine patient vital
signs including pulse, temperature, blood
pressure, and respiration”; and
• “Order and evaluate the results of labora-
tory tests relating to drug therapy including
blood chemistries and cell counts, drug levels
in blood, urine, tissue, or other body fluids,
and culture and sensitivity tests when per-
formed in accordance with guidelines or pro-
tocols applicable to the practice setting.”
IMS has submitted comments opposing
these rules. The activities described are the
practice of medicine. Physicians do not have
the legal authority to delegate the practice of
medicine to pharmacists, whether or not it is
done according to protocol or guidelines.
Pharmacists have a great deal of training
relating to use of drugs and their effects;
however, they lack training in direct patient
care including the diagnosis and treatment of
illness, and they do not have access to patient
medical records.
While there may be ways for physicians
and pharmacists to work more closely togeth-
er in many settings, the rules as proposed
provide no quality assurance mechanisms or
other patient safeguards.
For copies of the proposed rules and IMS
comments, contact Becky Roorda at the IMS.
Prior authorization for Medicaid drugs
The IMS was successful in efforts to remove
Ritalin from the list of drugs for which treat-
ment failure with the generic would be
required before it could be prescribed for a
Medicaid patient. The Department of Human
Services (DIIS) agreed to remove Ritalin from
the list because of studies showing the gener-
ic is not as effective as the name brand.
Watch your Medicaid informational mail-
ings for the list of generic drugs to be used for
Medicaid patients beginning September 1,
1995. These drugs have been classified by the
FDA as “A-rated generic bioequivalents” and
should be used in place of the name brand.
Treatment failure with the generic version
must be documented before the name brand
will be authorized by Medicaid. Prior autho-
rization will not be required for the generic.
IMS recommendations on Medicaid program
The IMS has made several recommenda-
tions to the state Council on Human Services
as it puts together the Medicaid budget and
legislative package for the 1996 legislative
session. Recommendations include improv-
ing low Medicaid reimbursement rates for
physicians.
While rate increases for obstetrical and
pediatric care over the last few years have
helped maintain access to these services,
other sendees should be reviewed for possi-
ble increases.
The IMS requested that DIIS consider the
burden placed on practicing physicians when
cost saving measures such as prior authoriza-
tion for prescription drugs are recommend-
ed.
While the IMS supports reasonable cost-
containment, measures which increase the
administrative burdens may have the unde-
sirable effect of decreasing access to physi-
cian services, particularly when combined
with low reimbursement rates.
The IMS also noted that the implementa-
tion of managed mental health care within
Medicaid has been problematic. While
expressing appreciation for the steps DHS
has taken to resolve problems, the IMS
encouraged the Council and DIIS to continue
to monitor the program and to work closely
with physicians on this and other managed
care programs.
Statute of limitations
With the able assistance of University of
Iowa medical student Eric Stone, the IMS is
compiling comprehensive information on
statutes of limitations for minors in medical
malpractice cases in other states.
The project includes information on
statutes and relevant court decisions and will
be the most up-to-date information available
in the country. This information will be used
to support IMS efforts to gain legislative pas-
sage of a reduced statute of limitations for
minors. E3
lie IMS is compil-
ing information on
statutes of
Imitations for
minors in medical
malpractice cases
in other states.
Iowa Medicine Volume 85 / 8 August 1995 319
Iowa | Medicine
Medical Economics
CURRENT ISSUES
New rules on medical records
AT A GLANCE
The media has focused
attention recently on the
policies being set by
insurers for obstetrical
patients. Though many
groups — including the
AMA — are questioning
the policies, more and
more insurers are limit-
ing length of hospital
stay to one day for
uncomplicated deliver-
ies. Recently, the Iowa
Farm Bureau Board of
Directors approved the
one-day stay for its
members. C-section
deliveries get a hospital
stay of three days.
•
According to a recent Iowa Administrative
Bulletin, the Industrial Services Division has
filed emergency rules regarding charges for
information from medical records in Workers’
Comp cases. The rules were effective May 17
and apply to Workers’ Comp cases only. IMS
has provided numerous comments on this
subject during the past two years.
Rules require medical providers to give an
employer or insurance carrier copies of the
initial and final assessments without cost
when needed to determine liability for a
claim or payment of a provider’s bill. Charges
are set for duplication of additional records
or reports that may be requested.
The rules provide that the fee structure
will be reviewed every year. For the first year,
the rules allow actual expenses or a base
charge ranging from $20 to §90 per record
plus 10 cents to $1 per page, depending on
the record’s length.
For more information, call IMS staff mem-
bers Becky Roorda or Barb Heck at 51/223-
1401 or 800/747-3070.
Participation is optional. The physician’s
software vendor will need to make special
arrangements in order to link directly with
Medicaid (through Unisys). There may be a
charge for the POS system from the physi-
cian’s software vendor.
For more information, call Ed Whitver of
the IMS staff, 800/747-3070.
Medicaid ID cards
The Department of Human Services has
established a work group to study a new
design for the format of the Medicaid ID card
and to determine whether the monthly
issuance of the cards should continue.
The DIIS hopes to determine how
Medicaid eligibility could be verified if
monthly ID cards are no longer issued.
Any physician who has comments on
these issues should contact Jan Walters at
515/281-6555 by the end of this month. You
may also mail comments to the DHS,
Division of Medical Services, 5th floor,
Hoover State Office Building, Des Moines, IA
50319.
A Minnesota judge has
refused to dismiss a
lawsuit filed by the
Minnesota attorney gen-
eral and Blue Cross/
Blue Shield of Minnesota
against the tobacco
industry. The suit is
aimed at recouping
health care costs of
smokers. The tobacco
industry had argued
that the plaintiffs had
no grounds to bring the
claims.
Medicaid Point of Sale
Beginning October 1, Medicaid will offer
physicians the option of submitting claims
electronically through their Point of Sale
(POS) system.
This means that while the patient is still in
the office, the physician can electronically
transmit the patient name, ID number, pro-
cedure performed, diagnosis codes, charges
and date of service directly to Medicaid.
Medicaid will instantaneously transmit the
patient’s Medicaid eligibility status back to
the physician. The claim will be processed
that weekend with checks written and mailed
to physicians on Monday.
The advantages for physicians are confir-
mation of Medicaid eligibility and payment at
the time of service and faster payment.
Medicare access report from PPRC
The Physician Payment Review Commis-
sion (PPRC) recently released a report on
access for Medicare patients. According to
the report:
•Access to medical care is good for most
Medicare patients, but vulnerable groups of
patients (African-Americans, rural and urban
poor) still have a problem. The biggest prob-
lem for these groups is access to preventive
care.
•The percentage of assigned claims is over
90% nationally.
•72% of all doctors are participating and
87% of all Medicare Part B claims are submit-
ted by these doctors.
•89% of all Medicare patients have some
type of supplemental coverage. H3
320 Iowa Medicine Volume 85 / 8 August 1995
Iowa I Medicine
CURRENT ISSUES
Practice Management
Medical Business Specialist graduate
Mary Staub, office manager for Anthony
Lazar, MD, Burlington, is the first graduate of
the Medical Business Specialist (MBS) certifi-
cation program. The program began in March
of 1994 and consists of 10 medical business
seminars. It is certified by the IMS and
endorsed by the Iowa Medical Group
Management Association (IMGMA).
Mary began the program March 18, 1994
and completed her courses June 21, 1995.
She successfully completed all exams.
“The IMS Services MBS program has been
great,” Mary commented. “No matter how
long you’ve worked for a physician, this pro-
gram offers seminars that no technical school
could do as well. I especially thank my spon-
sor/employer Dr. Anthony Lazar. I’ve accom-
plished my goal and he now has the first cer-
tified Medical Business Specialist in Iowa.”
There are 52 enrollees in the MBS pro-
gram. For more information, contact Sherry
Johnson at IMS Services, 800/728-5398. E3
Mary Staub displays her MBS certificate.
Midwest Medical Insurance Company
Focus on Risk Management
Malpractice gap
The underlying cause of many patient
injuries and malpractice claims is the failure
of clinics to implement and maintain systems
to follow up on important information. You
face almost certain liability if patient infor-
mation that is, or should be, known to you
“falls through the cracks” and an injury or
failure to diagnose occurs as a result.
We call this the “malpractice gap”.
Common failures of follow-up systems seen
in malpractice claims include:
•Failure to obtain results of diagnostic
tests ordered.
•Failure to bring the results to the atten-
tion of the physician.
•Failure to notify patients of the test
results.
•Failure to follow up on significant missed
or cancelled appointments.
Clinic systems should be designed to con-
sistently manage information, paperwork
and records. Remember the Three Rs when
designing your systems: Receipt of informa-
tion, Review of information and Report the
information.
For further information, contact Lori
Atkinson, MMIC risk management coordinator,
MMIC West Des Moines office, PO Box 65790,
West Des Moines, Iowa 50265. 800/798-9870 or
515/223-1482.
Practice Management Workshops
Quality in the Medical Office
Wed., Sept. 6 Sioux City
Wed., Sept. 20 IMS headquarters
Wed., Sept. 27 Burlington Medical Center
This course examines trends in quality including
outcome measures and practice parameters.
For more information or to register for any IMS
practice management workshop, call Sherry
Johnson at IMS Services, 515/223-2816 or 800/728-
5398.
AT A GLANCE
Are you keeping up on
developments with the
Community Health Man-
agement Information
Sy stern (CHMIS)? In
less than one year, Iowa
physician offices will be
required by law to com-
ply with CHMIS require-
ments. For the latest
information and how it
will affect your office,
check out the editorial
on page 31 7 by Terrence
Briggs, MD, chair of the
IMS CHMIS Committee.
•
There is still time to reg-
ister for a seminar enti-
tled “Survival Tactics in
the Medical Office”
being held in Omaha,
West Des Moines and
Cedar Rapids later this
month. Jack McDermott
will lead the discussion
on administrative phil-
osophies and adapting
your management style
to the practice. To regis-
ter, call Sherry’ Johnson
at IMS Services,
800/728-5398.
Iowa Medicine Volume 85/8 August 1 995 321
Iowa [Medicine
Newsmakers
|
1
AT A GLANCE
The University of Iowa
Hospitals and Clines has
been named one of the
nation’s leading hospi-
tals in a new edition of
The Best Hospitals in
America. The UIHC is one
of only 74 hospitals in the
U.S. listed in the book,
published by Gale Re-
search, Inc. Choices were
based on recommenda-
tions of physicians from
around the country and
on information from gov-
ernment sources, profes-
sional and popular pub-
lications and surveys or
interviews with about
150 hospitals.
♦
The UI College of Medi-
cine recently received the
Silver Achievement
Award of the American
Academy of Family Phy-
sicians, in recognition of
the fact that 32% of the
graduating medical stu-
dents in 1 995 chose fam-
ily practice as their spe-
cialty.
“Break the Silence, Begin the Cure”
Dear Editor:
We are returning the domestic abuse video-
tape you loaned us. At last, we as staff person-
nel, have been able to make the needed impres-
sion on our physicians.
This tape was used at a staff meeting. As
office manager, I had on hand the poster, bro-
chures and cards from
the domestic violence
break-out session of
the IMGMA. At that
time I was very im-
pressed with the video
and knew this would
make a tremendous
teaching staff meeting.
I have contacted the Domestic Violence
Center and requested pamphlets and cards for
our office. The Center has also given us addi-
tional ideas and suggestions for an ob/gvn of-
fice. We are excited that perhaps, in some small
or unknown way, we have a chance to help
someone in need.
Thank you for making this valuable video-
tape available. We highly recommend it for the
medical profession. — JoAnn McKinnon, office
manager, Iowa Clinic, Des Moines.
Editor's note: The IMS domestic violence
videotape is available for loan to any IMS
member physician. Call Chris McMahon,
director of communications at 51 5/223-1 401
or 800/747-3070.
Awards, appointments, etc.
Three new physicians have joined Medical
Associates in Dubuque: Dr. Mitchell Manthey,
internal medicine; Dr. Mark Janes, internal
medicine and pulmonary medicine; and Dr.
Kim Riess-Sagers, internal medicine and
nephrology. Officials of Samaritan Health Sys-
tem, Clinton, recently played host to a number
of Russian physicians and medical profession-
als as part of a medical personnel exchange
Letter
to the
Editor
program which focuses on maternal and child j!
health. Two Medical Associates physicians di-
rectly involved in this effort were Dr. Robert
Donnelly, obstetrician/gynecologist and Dr.
Virgil Corpuz, pediatrician and advisor for the
Maternal/Child Health Program.
New members
Iowa City
Alicia Weissman, MD, family practice
Geralyn Zuercher, MD, family practice
Indianola
Gary Janssen, DO, family practice
Eileen May, DO, family practice
Knoxville
i\lan Sooho, MD, psychiatry
Mason City
Michael Blaekinore, MD, psychiatry
Katherine Broman, MD, family practice
Barbara Coulter-Smith, DO, obstetrics/gyne-
cology
Robert Cunard, MD, resident
Shawn Griffin, MD, resident
Eric Stenberg, DO, resident
Julie Waddell, MD, resident
Michael Weston, MD, resident
Mt. Ayr
Yogesh Shah, MD, family practice
Mt. Vernon
Pamela Talley, MD, family practice
Onawa
Paul Dudley, MD, family practice
Ottumwa
Mark Dillon, MD, internal medieine/emergency
medicine
Pella
Richard Posthuma, MD, family practice
322 Iowa Medicine Volume 85 / 8 August 1995
CURRENT ISSUES
Sioux City
Leslie Hershkowitz, MD, cardiology
John Marriott, DO, radiology
Lonnie Lanferman, DO, resident
Washington
Curtis Frier, DO, general practice
Chung Huang, MD, internal medicine
Lvnette lies, MD, family practice
Rey Clivi Lin, MD, internal medicine
Dennis Shimp, DO, general practice
Paul Towner, MD, family practice
Waterloo
Richard Korentager, MD. plastic surgery
Robert Miller, MD, cardiac surgery
Alyce Tyree, DO, resident
Deceased members
Kenneth Dolan, MD, 66, radiology, Iowa
City, died May 6
Edward Posner, MD, 76, life member, in-
ternal medicine, Des Moines, died Februaryl4
Kerry’ Jensen, MD, 59, family practice,
Clinton, died April 20
Edward DeLashmutt, MD, 71, general sur-
gery, Fort Madison, died May 5 HD
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Iowa Medicine Volume 85 / 8 August 1995 323
Iowa | Medicine
FEATURE ARTICLE
Christine McMahon
Ms. McMahon is director
of communications for
the Iowa Medical Society
and managing editor of
Iowa Medicine.
Physicians on the
Front Line
They saw a side of World War II that even the soldiers didn’t
see. Retired Des Moines physicians Dr. Ralph Dorner, Dr. John
Hess and Dr. Robert Stickler recall their harrowing
experiences treating the wounded during the Allied invasion of
Normandy and the Battle of the Bulge.
They never thought of themselves as
heroes and, a lifetime later, their modesty
survives intact.
“I told members of my surgical team that
the important thing was to be able to sit in
the quiet of our tents and decide we did the
best job possible with what we had to work
with,” comments Dr. Ralph Dorner, a retired
thoracic surgeon who landed on Utah Beach
with the Third Auxiliary Surgical Group on
June 7, 1944, D-Day plus one. “If we could do
that, we didn’t need to worry about
decorations.”
Dr. Dorner, Dr. John Hess and Dr. Robert
Stickler were in the thick of the action
treating wounded in World War II’s European
theater. They seem uncomfortable discussing
ribbons and medals and relate their medical
war stories quite dispassionately;
but it’s obvious the passage of
time hasn’t completely dimmed
memories of fallen comrades and
families waiting at home.
“The folks back home should
have gotten medals,” adds Dr.
Dorner. “They never knew when
we were in danger.”
Dr. Dorner’s trek toward Utah Beach began
when he sailed for England in December,
1942. He was stationed at Oxford for a time,
sent to Africa then back to England to
prepare for D-Day after the Sicilian campaign
was completed. Dr. Dorner’s worst memory of
the war was April 27, 1944 when he was in a
convoy of seven landing crafts doing beach
landing maneuvers.
“Three of our landing crafts were
torpedoed by German E boats. There were
750 boys killed. It was terrible.”
No x-rays, blood work or tables
When Dr. Dorner arrived on Utah Beach,
he found one field hospital already set up. He
helped set up another and was assigned to
triage. Oddly, his first case was a soldier with
appendicitis. He was on Normandy beach
about eight days, then he and his
team followed troops to the French
village of Ste. Mere-Eglise, the first
to fall to the Allies.
“We had no x-rays, no blood
work, no lab work. We used
universal blood which we had
because of Dr. Bob Hardin at the
University of Iowa. Our operating
“Triage was simple.
If they couldn’t he
moved 30 miles,
you did something
for them.”
Dr. Robert Stickler
324 Iowa Medicine Volume 85 / 8 August 1995
FEATURE ARTICLE
tables were litters on sawhorses and we used
lots of penathol.”
He recalls the difficulty of trying to
operate in a tent with an American tank
parked right outside engaged in non-stop
shelling. One case Dr. Dorner particularly
remembers was a soldier whose neck was
laid open and his thyroid cartilage divided.
“It was a very unusual wound. I did a
tracheotomy and patched him back
together,” he recalls. “We saw lots of unusual
land mine injuries. We did a lot of bowel
resections for bowel lacerations.”
Air compressor becomes suction machine
He also recalls that there was plenty of
ingenuity on the part of physicians.
“We had tent lights we made with plasma
cans as reflectors, and I recall in Africa we
went to a salvage dump looking for a suction
machine. The captain of the dump reversed
the tube on an air compressor with the swing
of an ax and a swish of his knife — great
suction. When we got ready to transport the
tracheotomized patient, a corporal rigged up
suction by hooking it to the windshield wiper
apparatus on the ambulance.”
After Normandy, Dr. Dorner and the Third
Auxiliary went “hedge hopping” from one
field hospital to another, following Allied
troops who were chasing the Germans.
In December of 1944, Dr. Dorner’s team
was sent 12 miles east of Malmedy, Belgium,
the center of the Ardennes bulge break-
through by the Germans on December 17.
Dr. Dorner and his team, in great jeopardy,
somehow managed to evacuate themselves
and their patients.
“I rode on the running board of an
ambulance,” he relates. Dr. Dorner achieved
the rank of major and is mentioned several
times in Front Line Surgeons, a book
containing eyewitness accounts by members
of the Third Auxiliary Surgical Group.
400-900 casualties a day
Dr. John Hess, a longtime Des Moines
family physician, enlisted in the Army when
he was a junior in medical school and went
into officer training in June of
1942. He shipped out of
Boston shortly before D-Day
and was placed in reserve for
the 82nd Airborne and the
102nd Airborne.
Within a few months, he
found himself heading up a
group of surgeons and other
medical personnel at the
Battle of the Bulge.
“We set up a hospital in an
old army barracks near a
small town in Belgium. We
gave them blood, started IVs
and shipped them out. We
took care of whoever was
brought in — even German
soldiers,” Dr. Hess relates.
Then, they moved to a
small Belgian hospital where
they saw “terrible casualties,
between 400 and 900 a day. One of my
biggest problems was disciplining the officers
not to spend time on people who were
beyond help.”
Frostbite, leg ulcers
Common injuries were burns, broken
bones, shrapnel and gunshot wounds —
mostly from artillery. There was also plenty
of frostbite and ulcers on legs from standing
in foxholes in the snow.
The Battle of the Bulge unfolded in such a
bewildering fashion, Dr. Hess relates, that
even medical personnel “never knew how far
continued
Iowa Medicine Volume 85 / 8 August 1995 325
In the dim light of the tent , one
casualty looked like another. Actually,
no two were alike. There was no
telling what the wounds would show ;
once the bloody blankets had been
discarded and the clumsy dressings
cut away. There might be just one
small puncture wound or there might
be a hundred jagged lacerations. One
man with a tiny perforation in the
flank might be in profound shock
while the next one with part of his
intestines out on the abdomen would
nonchalantly ask for a cigarette/ '
From Front Line Surgeons by Clifford Graves.
Iowa I Medicine
FEATURE ARTICLE
continued
“There were
casualties
everywhere. Sixty
members of our
group of 240 were
killed during the
Sanding.”
Dr. John Hess
we were from the front lines”.
Dr. Hess was at the Battle of the Bulge for
two weeks and was then sent back to France
to prepare for an airborne mission across the
Rhine into Germany. lie and the other
surgeons went in on gliders, an extremely
risky business.
“After Normandy, very few doctors para-
chuted because in those conditions and with-
out supplies or equipment, a doctor became
little more than an aid man,” he says.
The morning of the glider mission, Dr. Hess
had an emesis after breakfast. He assumed his
nausea was caused by apprehension.
“We knew where we were going,” he
recalls. “We knew it was going to be a bad
deal. As we were flying over the woods, all I
could see were muzzle blasts from 20
millimeter aircraft guns aimed right at us.”
Chest surgeon killed
The gliders landed under fire and Dr. Dess
lay where he landed without moving for
nearly an hour.
“There were casualties everywhere. Sixty
members of our group of 240 were killed
during the landing.”
One of those killed, he remembers, was a
chest surgeon front Massachusetts General.
“There were no marks on him and we
couldn’t figure out what had killed him until
later when we examined him more closely.
An explosive shell had entered his rectum
and ruptured his aorta.”
Dr. Hess’ team set up a field hospital near a
schoolhouse and, within a few hours, Dr.
Hess discovered why he had vomited the
night before.
“I had hepatitis and didn’t even realize it
until I urinated. I took an orange juice
substitute, dug a fox hole and lined it with
abandoned parachutes,” he says.
He stayed in the fox hole for three days,
getting up only to make rounds twice a day.
At night, he watched tracer bullets lighting
up the sky above him. Finally, he was
transported to a hospital in Le Mans, France,
where he stayed for three months receiving
the only hepatitis treatment available — rest
and a proper diet.
By the time he had recuperated, the war
was officially over and he was assigned to the
82nd Airborne occupying Berlin.
“I was with one of the first groups into
Berlin. It was a pile of bricks.”
Conditions in Berlin were abysmal.
Starving Berliners, shunned by rural
Germans, did anything for food. Dr. Hess
admits to being shocked by the ways some
people took advantage of the others’
hardships. The Russians, he recalls, were
particularly merciless to the displaced
Germans.
To top it off, he was assigned a laundry
woman who was “a dyed-in-the-wool Nazi”.
“She hated me and I felt the same about
her,” he admits.
In October of 1945, Dr. Hess learned that
he and other physicians might be sent home.
However, the Russians informed the Allies
326 Iowa Medicine Volume 85 / 8 August 1995
FEATURE ARTICLE
that, if they sent them home, they could not
replace them in Berlin.
“So, instead of going home, I got a two-
week leave in Switzerland. That was the first
time I was able to call my wife and hear
about our son who was born in February,”
says Dr. Hess.
Kept going until they ran out of gas
Dr. Robert Stickler, a Des Moines general
surgeon, was called from reserve to active
status after Pearl Harbor and was sent to
France after the D-Day invasion.
“We worked out of trucks doing makeshift
operations,” he says. “Triage was simple. If
they couldn’t be transported 30 miles, you
did something for them.”
He says surgeons on the front line did no
definitive bowel surgery.
“We resected the bowel, cut away the
dead tissue and sewed them up. We did no
vascular work, we just amputated.”
Dr. Stickler and other surgeons tagged
along behind Allied troops through France.
“We played leap frog with three trucks. One
was our sterilizing unit, one was gearing up
and the other was in operation,” he explains.
“We kept going until we ran out of gas and
someone came along with a new supply.”
Following the armored tanks was difficult
because the Germans fired mortars at them
continually. However, he doesn’t recall being
frightened.
“Fear was something that developed
gradually as time went on. It’s strange, but I
didn’t have any great anxiety until after the
war was over.”
Snow, isolation at the Battle of the Bulge
Eventually, Dr. Stickler was assigned to
General George Patton’s group, the 10th
armored division, and ended up at the Battle
of the Bulge.
“That was isolation. We couldn’t even
evacuate our wounded,” he recalls.
In addition to the isolation and shortages
of supplies, the weather was cold and snowy,
making the conditions extremely difficult for
working and living.
“We did without some of the frills . . . like
gloves. We relied a great deal on sulfa
crystals,” he says. “In the field hospital, the
first guys in got the best treatment.”
Dr. Stickler and other surgeons treated
wounded soldiers in chicken coups, next to
stone walls, anyplace that offered a bare
modicum of shelter or windbreak. Dow was he
able to tolerate the physical hardships?
“I was young,” he says with a smile. “One
continued
This map depicting the
Battle of the Bulge is
contained in a book called
Front Line Surgeons. The
book tells the story of the
Third Auxiliary Surgical
Group, of which Dr.
Dorner was a member.
The note on the map is Dr.
Dorner’s. Drs. Hess and
Stickler were also at the
Battle of the Bulge.
Iowa Medicine Volume 85 / 8 August 1995 327
Iowa | Medicine
FEATURE ARTICLE
continued
Dr. Dormer kept a surgical
diary which contained an
account of each patient
he treated.
3398
2 Last name
WILSON
5 Grade
Pvt
BGEU
3 Fltfsl namaand middle initial 4 A. S. No.
Grover C 35706128
<•»> 9 Race
W
7 Regiment and Arm or Service
314 Inf
8 Age
_12_
Kz_
11 Service
11/12
(b> 13 Source of admission
14 Register numbers or. hospital memoranda:
1. Shell wounds, (HE), left flank,
multiple, severe, just above left
iliac crest, entering abdomen and
perforating small intestine in six
(6) places, and descending colon in
one (1) place.
2. Cecostomy, McBurney region, sec-
ondary to #1.
Incurred 8 Jul 44, about 2200 hours
2 miles from St. Lo, France while
scouting during start of attack on
enemy position, when injured by ex-
plosion of 88mm shell. WIA.
LD — 1 & 2 Yes.
Evacuated to the 2 of I - 9 Sep 44.
15 Name of Hospital
188 GH
u) Fill in as: Register Index, Diagnosis Indei, Disability Index, Death
Index, Out-patient Index, or Venereal Report Card, as appropriate.
u>> Spaces 6 to 13 inclusive not to be filled in when form is used for lighter
Index in time of peace and in the Zone of the Interior in time of war.
thing 1 remember very well is receiving the
IMS Journal. It was my major source of
medical information. ”
Dr. Stickler admits to hating blackouts —
which he remembers as “heavy and oppres-
sive” — but he is philosophical about war.
“As you get into it, things are put into a
different perspective. You lose your veneer.
I’m afraid there’s no time to be nice.”
Following the
Battle of the Bulge,
Dr. Stickler was
assigned to the 7th
Army and sent to
the resort areas of
Austria. Ilis job was
to look for German
SS officers who
were hiding in the
hospitals.
“The German
officers faked injur-
ies so they could
escape detection. I
remember finding at
least one,” he says.
After he com-
pleted this assign-
ment, he was sent
to Paris to await
transport hack to
America. Unfortun-
12 Date of admission
30 Aug 44
Form 62 a
Medical Department, U. S. A.
(Revised March 15, 1938)
ately, Uncle Sam
wasn’t finished with
Dr. Stickler and he
found himself on a
ship bound for the Philippines. The ship got
as far as the Caribbean when the war in the
Pacific ended.
“I’ll never forget the moment when the
captain turned the ship around and we
headed for home,” he says.
The legacy of war
On his son’s 40th birthday, Dr. Mess took
him to Europe to visit many of the places he
knew from war. Dr. Dorner attends periodic
reunions of the Third Auxiliary Surgical
Group and plans a visit to England and
France in September. Dr. Stickler has not
returned to Europe since he was discharged.
Dr. Hess “wouldn’t want anyone to go
through what I went through” but is glad he
had the experience; Dr. Dorner “wouldn’t
give a nickel for the whole thing”, but
wouldn’t give it up for a million dollars.
However, for Dr. Dorner, the most
persistent legacy of the war is even simpler.
“Little things don’t annoy me much,” he
says calmly. Ei3
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Let Us Help You!
328 [o'wa Medicine Volume 85 / 8 August 1995
/VIERCY
HOSPITAL
MEDICAL
CENTER
Mercy Hospital Medical Center
preienti
"INFECTIOUS DISEASE: MILESTONES AND MYTHS''
Wednesday, September 13, 1995
Guest Faculty Topics
Terry Yamauchi, M.D "Immunizations: New News!"
Professor of Pediatrics
University of Arkansas College of Medicine
Little Rock, Arkansas
Robert Rapp, Pharm.D "Fungal Infections: Prescribing Issues"
Director, Pharmacy Practice and Science
University of Kentucky
Lexington, Kentucky
Douglas Dieterich, M.D "Gastrointestinal Disease in the
Associate Professor of Medicine Immunocompromised Host"
Division of Gastroenterology
New York University School of Medicine
New York, New York
Patricia Quinlisk, M.D "Tuberculosis in Iowa"
State Epidemiologist
State Department of Health
Des Moines, Iowa
Ravi Vemuri, M.D "Legionellosis"
Infectious Disease Specialist
Mercy Hospital Medical Center
Des Moines, Iowa
Approved by Mercy Hospital Medical Center, an . Physician Fee $50.00
IMS-accredited CME organization for 4 hours of . Physician Assistant $25.00
Category I AMA Physician’s Recognition Award. . Nurses $25.00
Nursing Personnel $25.00
Nursing CEUs: 0.5 (5 Contact Hours) . Pharmacists $25.00
Application has been made for additional accredita- . Paramedical $25.00
tions. See brochure. Resident/Student Complimentary
This seminar will be held at the Mercy Education Center, Fifth Street and University Avenue,
Des Moines, Iowa. Parking adjacent to the Education Center.
Please contact: Department of Medical Education • Mercy Hospital Medical Center
400 University • Des Moines, Iowa 50314-3190 • 515-247-3042
Iowa[ Medicine
GME Seminars
Family Practice
AT A GLANCE
Advertise your continu-
ing medical education
seminars or workshops
in this section by calling
Jane Nieland or Bev
Corron at the Iowa Medi-
cal Society, 515/223-
1401 or 800/747-30 70,
fax 515/223-8420 or send
copy and payment to
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Cost is S 25 per insertion
up to 10 lines. Deadline
is the first of the month
preceding publication.
4th Annual Child Protection: Our Responsi-
bility
September 14-15, 1995
Sheraton Inn, Cedar Rapids, Iowa
Physicians $210 if registered before August IS
AMA Category 1, 13 credit hours
Contact St. Luke’s Child Protection Center, St.
Luke’s Hospital, Cedar Rapids, Iowa, PO Box
3026 Cedar Rapids, IA 52406; 319/369-7908
Miscellaneous
Women’s Health '95
September 15, 1995
Drake University, Olmstead Center, Des
Moines, Iowa
AMA Catgegorv 1 credit
Contact Drake Meeting Resources, 515/288-
4543; fax 515/288-4745
CLARKSON MEDICAL
LECTURE SERIES
November 17, 1995
8:00 a.m. - 5:00 p.m.
Advances in
Primary Care:
Building on the
Legacy
Clarkson Hospital
Omaha, Nebraska
(Storz Pavillion)
For more information call
1-800/647-5500, ext 3039
402/552-3039
Is your medical staff or county medical society looking for a CME program idea?
Why not consider the Iowa Medical Society domestic violence videotape!
This 27-minute video is getting rave reviews from physicians and other
health care professionals, clinic managers and domestic violence advocates.
The video contains Iowa domestic abuse experts and is aimed at educating
Iowa physicians on how to manage victims of domestic abuse.
Any IMS member physician may borrow the videotape by calling Chris
McMahon, IMS director of communications, at 800/747-3070 or 515/223-1401.
IMS staff can also provide written materials to accompany the videotape.
Don’t miss out on this opportunity to learn more about domestic abuse in Iowa
and how you can help your patients.
330 Iowa Medicine Volume 85 / 8 August 1995
Iowa I Medicine
SCIENCE AND EDUCATION
The Journal
of the Iowa Medical Society
flir pellet gun injury
# Daniel Waters, DO; Benjamin Broghammer, MD; R. Mark Duff, MD
A seven-year-old male sustained a com-
pressed air pellet gun injury to the thorax at
close range (<2 m). The child was brought to
the emergency department (ED) at the local
county hospital. Initial examination revealed
an apprehensive child who exhibited some
mild respiratory splinting, but no signs of res-
piratory distress. Blood pressure was 118/76
mm Hg with a respiratory rate of 28/min and
a pulse rate of 106 bpm. Initial chest radi-
ograph (see Figures la & lb next page)
revealed a radiopaque foreign body at the
inferior left heart border. No pneumothorax
was noted.
The patient was transferred to a regional
referral facility. Examination in our ED
revealed no change in hemodynamic status.
An entrance wound was noted just lateral
and inferior to the right nipple. There was no
identifiable exit wound. The pellet could not
be palpated beneath the skin of the thorax or
abdomen. No paradoxical pulse was noted.
Arterial blood gases on room air were nor-
mal. An electrocardiogram showed only sinus
tachycardia. Repeat chest radiography
showed no discernible change in the position
of the pellet. Chest fluoroscopy in the anteri-
or-posterior projection demonstrated the pel-
let to be “spinning” with cardiac motion.
Changing the position of the patient did not
change the position of the pellet.
Non-contrast computed tomography of the
chest showed no evidence of pneumothorax
and suggested that the pellet was located in
the anterior mediastinum. Because of the sig-
nificant amount of “scatter” created by the
pellet, however, definitive location could not
be determined. Two-dimensional echocardio-
graphy showed the pellet to be extracardiac
but within the pericardium near the ventric-
ular apex. There was no evidence of tampon-
ade or pericardial effusion.
The child was managed expectantly. Serial
echocardiograms showed no change in pellet
position and no pericardial fluid accumula-
tion. Serial cardiac isoenzymes determina-
tions were normal. The patient remained sta-
ble and asymptomatic and was discharged on
the third hospital day. Follow-up chest x-ray
at three and 14 months showed no change in
the cardiac silhouette or the location of the
missile. A subsequent magnetic resonance
imaging study failed to visualize the lead pel-
let, despite a chest x-ray confirming its origi-
nal position. The child remains well and
asymptomatic.
Discussion
With the proliferation of high-powered,
high-velocity weapons, especially in urban
areas, the incidence of penetrating chest
trauma in children has become more com-
monplace. It is a misconception that because
missiles fired from pellet guns are not explo-
sive powered, they are not capable of induc-
ing serious physical injury. Thus, many such
pneumatic weapons end up in the hands of
children because adults may feel that they
represent a lesser risk of physical danger.
Multiple case reports in both the thoracic
surgical and pediatric literature belie this
assumption.1 5
The ability of a given bullet, pellet or pro-
jectile to penetrate the body is generally
determined by its muzzle velocity.4 Although
pneumatic weapons (pellet guns, BB guns,
etc.) are classified as low-velocity, they are
associated with both morbidity and mortality.
The perception of such weapons as toys is an
unfortunate one.
Ballistic analysis has shown that an air
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
August 1995.
Daniel Waters, DO
Benjamin
Brogilammer, MD
R. Mark Duff, MD
The authors are with the
Departments of
Cardiothoracic Surgery,
Radiology and Pediatrics,
North Iowa Mercy Health
Center, Mason City,
Iowa.
Iowa Medicine Volume 85 / 8 August 1995 331
Iowa I Medicine
SCIENCE ft N D EDUCATION
Air pellet gun injury
continued
Figure 1. Posterior-anterior (a) and lateral (b) chest radiographs
demonstrating pellet location.
rifle, if adequately pumped, can potentially
produce a muzzle velocity of up to 900 feet
per second (fps). It has been reported that a
muzzle velocity of approximately 350 fps is
sufficient to break the skin and cause damage
in deeper soft tissue.4 Not only has death
been reported as a result of pellet gun injury,
but so has significant morbidity including
ventricular laceration, cardiac tamponade,
pneumothorax and cerebral and peripheral
pellet embolization.1 6 Small pellets within a
left-sided cardiac chamber are more prone to
embolizing to the cerebral circulation.6 Often,
retrieval of a pellet and/or treatment of asso-
ciated injury requires a major thoracic surgi-
cal procedure and the use of cardiopul-
monary bypass.2-6
In the child who presents with severe
hemodynamic or respiratory compromise,
exact localization of the pellet becomes sec-
ondary to treatment of life-threatening
injuries. In the minimally symptomatic child,
however, accurate determinate of projectile
location is of great importance in determining
both initial and long-term management. The
standard chest radiograph, while it may indi-
cate the presence of a penetrating cardiac or
throacic injury, is generally considered to be
inadequate for localizing these projectiles.7 GT
scanning is feasible, but is hampered by the
variable amount scattering of the radiation by
a metallic projectile with resultant distortion
of the radiographic images. Nuclear MRI may
be useful in determining the location of non-
ferrous missiles, but it is hampered by the fact
that often in the acute situation, the exact
metallic composition of a given projectile is
uncertain.8 Several reports have discussed the
use of echocardiography as a means of accu-
rately assessing not only pellet location, but
also for diagnosing associated cardiac
injury.7010
Perhaps the most important determination
to be made in penetrating cardiac injury is
whether the missile is intracardiac, intramy-
ocardial or extracardiac. Intracardiac projec-
tiles, i.e. those retained within one of the
atria, ventricles or great vessels, are generally
recommended for surgical removal. Some
authors, however, recommended that a right-
sided intracardiac missile which is not associ-
ated with other cardiac injuries does not nec-
essarily have to be surgically extirpated.
Left-sided intracardiac projectiles, because of
the possibility of cerebral or peripheral
embolization, are almost universally recom-
mended for removal unless they are deeply
embedded in the myocardium and not associ-
ated with other significant injuries.11
Little has been written about projectiles
which lodge within the pericardial space with-
out associated cardiac injury. In the absence
of hemodynamic or respiratory compromise,
pericarditis or systemic infection, non-opera-
tive management— especially in the pediatric
patient — may be preferable. Post-pericardioto-
my syndrome has been reported with a
retained foreign body, however.12
Conclusion
Air gun missile injuries in children can be
associated with significant mortality and mor-
bidity. For the clinician presented with a
child who has sustained a chest wound from
such a weapon, a high index of suspicion for
occult cardiac or pulmonary injury must be
maintained. The general adult public may not
take the potential for injury from pneumatic
weapons very seriously. Physicians must
avoid the same mistake.
References
References noted in the article are avail-
able either from the authors or the editors of
Iowa Medicine. ED
332 Iowa Medicine Volume 85 / 8 August 1 995
Iowa | Medicine
THE EDITOR COMMENTS
Looking back and
finding change
During recent months, war veterans
have been reminded of World War II
with tours and celebrations at
Normandy Beach and surrounding
countryside. Many American veterans have
: returned to the battlefields. Their hearts and
minds have been filled with sad nostalgia,
memories of their fallen comrades in arms
and personal gratitude that they personally
lived through that horrible historical event.
I, among many, was fortunate that I did
not face combat during my years of active
duty during World War II, as well as during
the Korean Conflict. Though still in the
Naval Reserve and subject to recall to active
duty, I fortunately escaped the Vietnam War.
Recently while visiting our daughter in
Seattle, I sought the locations of
my active duty while there in
1951-1952. Our base was Pier 37
along the waterfront of downtown
Seattle. At first glance I could not
locate anything familiar. After 43
years, change had converted the
nearby piers to shipping points for
containerized cargo; no Navy
facility present.
Then, I sought out the Navy Receiving
Station where I was billeted when not at sea.
Most of the facility was gone and the area
was occupied by hundreds of new cars from
Japan. The passing years had done it again.
Alongside there was a large private marina
where our daughter and her husband keep
their boat.
Next, we went over to Bremerton, where I
served some detached duty at the Naval
Hospital. We did not go ashore, but the piers
were packed with fighting ships in “moth
balls.” There lay the USS Missouri, USS
Ranger, USS Nemitz, USS New Jersey, a
number of destroyers and numerous
submarines. One could not avoid thinking of
what the officers and men experienced on
those noble warships.
This type of adventure in nostalgia can be
revealing. We oldsters can look back on how
the practice of medicine was four to five
decades ago. We can go back to high school
and college reunions and renew old
friendships. Too many of us live for the
future and cast the past aside. That is
unfortunate, because we ex-
perience rewards imprinted on
our memories by living some of
the past. Life becomes more full
and we profit from such recall.
Don’t be caught in a rut along the
pathways of the present; don’t be
disillusioned by perceived future
events; live in the past as well to
enrich your total life. Better yet, relate to
your children and grandchildren stories of
your past. At first they may think old
grandpa is living too much in the past, but
like all history the stories become more
interesting with succeeding years. E3
We oldsters can
look back on
how the practice
of medicine was
four to five
decades ago.
Marion Alberts, MD
Iowa Medicine Volume 85/8 August 1 995 333
IowalMedieine
AMA Delegates Determine Medicine’s Agenda
The AMA House of Delegates — including the Iowa Medical Society’s delegation — addressed a number of key health
care issues at its annual meeting June 18-22 in Chicago. Following is a summary of actions. Members of the IMS
delegation are Dr. Clarence Denser, Dr. Donald Young, Dr. Clarkson Kelly, Dr. Bruce Trimble, Dr. Daniel Youngblade, Dr.
Thomas Graham, Dr. Bryan Pechous and Dr. Bernard Fallon.
Physician participation in capital punishment: evalu-
ations of prisoner competence to be executed — This
report concludes that physician participation in evalua-
tions of a prisoner’s competence to be executed is ethical
only when certain safeguards are in place and that when
a condemned prisoner has been declared incompetent to
be executed, physicians should not treat the prisoner to
restore competence unless a commutation order is is-
sued before treatment begins.
Perinatal discharge of mothers and infants — Perinatal
discharge of mothers and infants should be determined
by the clinical judgement of attending physicians and
not by economic considerations.
Professionalism and medical ethics — Resolved that
the AMA reaffirm that the medical profession is solely
responsible for establishing and maintaining medical
ethics and that the state cannot legislate ethical stan-
dards or excuse physicians from their ethical obliga-
tions. Specifically, this resolution examines the AMA’s
opinion that it is unethical for health professionals to
participate in state ordered executions.
Medicare transformation — The House of Delegates
passed this amended report which outlines the AMA’s
proposal for transformation of the Medicare system. This
platform will be used for negotiations with Congress in
coming months. The report deals with a full spectrum of
issues from limits on residency slots to cost sharing.
Criminalization of health care decision-making —
The AMA opposes the criminalization of health care
decision-making especially as represented by the cur-
rent trend toward criminalization in malpractice; it
interferes with appropriate decision-making and is a
disservice to the American public. The AMA will educate
opinion leaders, elected officials and the news media
regarding the detrimental effect on health care resulting
from the criminalization of decision-making.
Tobacco company liability — The AMA will oppose any
provision of tort reform legislation that would give exclu-
sion from liability or special protection to tobacco com-
panies or tobacco products.
Medical specialty choice — The AMA supports mea-
sures to increase the availability of information on spe-
cialty choice to medical students and resident physicians
by gathering and disseminating information on market
demands and physician workforce needs for all special-
ties.
Nonphysician relations — The AMA reviewed its guide-
lines regarding the professional relationship between
physicians and nurse practitioners/physician assistants.
Discussion focused on adding and strengthening refer-
ences to the supervisory responsibilities of physicians in
all practice settings.
Violence against health care workers — The AMA House
passed policy that supports the development of model
state legislation to criminalize violence and threats of
intimidation against all health care workers and their
families.
In-line skating — In response to a dramatic increase in
the number of in-line skaters and in-line skating acci-
dents, the AMA House passed policy to recommend that
all in-line skaters wear protective helmets, wrist guards,
elbow and knee pads. Further, the policy recommends
this safety equipment be available at the point of in-line
skate rental or puchase and encourages efforts to educate
adults and children about in-line skating safety.
Music rating system — In response to continued concern
over the potential negative impact of destructive themes
in some music, the House passed policy calling for the
development of model state legislation to regulate the
lyrical content and/or distribution of such music to indi-
viduals under age 18. The policy also calls for the AMA to
work with the music industry to develop a rating system
to identify recordings containing violent lyrics.
Physician hand washing — Observing the sesquicenten-
nial of Semmelweiss’ observation that hands washed in
chlorinated lime before examining patients reduced the
spread of infection, the AMA reminded physicians that
they have a professional obligation to wash their hands
with an antiseptic before and between each patient en-
counter.
334 Iowa Medicine Volume 85/ 8 August 1995
Iowa [Medicine
PHYSICIAN LEARNER
When physicians learn
from colleagues
Note: This is the first of three articles on
interdisciplinary CME. Subsequent articles
will focus on physician learning from other
health care disciplines and physician learn-
ing from other professions.
Planners of CME events and resources are
continually in search of the correct de-
nominator in marketing their wares. This
is an easy task for the specialty societies. The
CME content is directed to the level of expertise
and interest of members of the particular soci-
ety. While physicians who represent other
specialties may be welcome to attend the con-
ference or use the learning resource, the con-
tent is most likely to reflect developments and
controversies within the sponsoring specialty.
The planning task becomes a greater chal-
lenge when the target audience
includes more than one physician
specialty. A number of questions
emerge. Which specialty is the
principal audience? Will the in-
structors also largely be members
of that specialty? Is there an
“agenda” through which one spe-
cialty is attempting to bring a mes-
sage to another?
Never have such issues been so well illus-
trated as in planning for CME in the field of
primary care. Primary medical care is not the
sole province of any single specialty. There is
controversy regarding what specialties are le-
gitimate bearers of the title of primary care
physician. Historically some CME primary
care programs have essentially been planned by
one group of specialists for a second group or
they have been developed by a speciality for
that specialty and not for any other specialty!
Such approaches frustrate the opportunity
for one specialist to learn from another who is
in a different medical discipline. Advances in
medical therapeutics then inevitably progress
at varying rates within the clinical practices of
the disciplines. Cross-fertilization is hindered,
and in the worst scenario, the different disci-
plines adhere to contradictory practice stan-
dards that undermine the profession with the
public.
Interdisciplinary CME is essential for pool-
ing the broad experience of specialties in the
prevention, evaluation and management of
human disease. As CME consumers, physicians
should be alert to the signs of a
healthy interdisciplinary offering.
Is the conference or material pub-
licized among multiple specialties?
Do the planners represent the ap-
propriate disciplines? Are the pre-
senters at a conference represen-
tative of the target audience? Is
discussion encouraged among the
specialists?
Physicians can and should learn from their
colleagues in other specialties. Look for the
appropriate vehicle that facilities such learn-
ing. ED
Physicians
can and should
learn from
their colleagues
in other
specialties.
Richard Nelso.x, MD
Iowa Medicine Volume 85 / 8 August 1995 335
Iowa [Medicine
Classified Advertising
Emergency Medicine
Director
Air/Ground Transport
Waterloo, Iowa
This is a rare opportunity to be a
team leader in an outstanding
medical facility.
• Level II Trauma Center
• Regional Referral Center
• 25,000 Annual Volume
• 12-Hour Shifts
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• Regionalized 911
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• Generous Compensation Package
• Paid Malpractice Insurance
• Health /Dental, Life, Disability
Staff positions also available.
Send CV or call Sheila Jorgensen
EMERGENCY PRACTICE
ASSOCIATES
PO Box 1260, Waterloo, Iowa 50704
800/458-5003 or fax 319/236-3644
Des Moines — IM, FP, PD needed to join
growing elite practice! Above average salaries,
good call coverage, excellent benefits. Call
Mary Latter at 800/520-2028! Job #M141MJ.
Van Buren County
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Seeking quality primary care
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• 2400 annual volume
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Send CV or contact
i Melissa J. Milliken, CMSC
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j\ ACUTE CARE, INC.
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' PO Box 515, Ankeny, LA 50021
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Fax 515/964-2777
No Assembly Lines Here — FPs, IMs and OB/
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Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: acute/urgent
care, family practice, oncology/hematology,
orthopedic surgery and general internal
medicine practice. The Mankato Clinic is a
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population of +250,000. Guaranteed salary
first year, incentive thereafter with full range
of benefits and liberal time off. For more
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or write 1230 East Main Street, P.O. Box 8674,
Mankato, Minnesota 56002-8674.
Stoughton, Wisconsin — Dean Medical Center,
a 350-physician multispecialty group is
actively recruiting a BE/BC family physician
for our Stoughton Clinic, which is located
approximately 20 miles south of Madison
(population 190,000). Currently there are 3
internists, 4 family practice physicians, one
pediatrician and one general surgeon at this
clinic. Call would he shared equally among
the family physicians. The Stoughton Hospital
is a 50-bed facility adjoining the new medical
office building. Stoughton has a population of
approximately 9,000 and growing with
excellent schools and neighborhoods. This is
an excellent position which enables you to live
in a safe community with the cultural and
professional resources of a larger city just
minutes away. A two-year guaranteed salary
plus incentive and benefits is being offered for
this position. Contact Scott Lindblom, Dean
Medical Center, 1808 West Beltline Highway,
Madison, Wisconsin; 1-800/279-9966; 608/250-
1550 (work); 608/833-7985 (home); or fax
608/250-1441.
Marshalltown Medical
& Surgical Center
Seeking quality primary care
trained or emergency medicine
physician to practice at MMSC.
• Stellar EM practice
• Full-time, regular part-time and
moonlighting opportunities
• 14K annual volume
• 12-hour shifts, 24-hours/7day
coverage
• Excellent benefit/bonus packages
• Paid St. Paul malpractice
Send CV or contact
i Melissa J. Milliken, CMSC
acute care, inc.
PO Box 515, Ankeny, LA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Springfield. Missouri — Bass Pro Shop and 40
miles to Branson. BE/BC FPs. OB optional,
salaried position and production bonus, call
1:7, teaching hospital, university community.
Contact Vivian M. Luce, Cejka & Co., 1/800-
765-3055 or fax CV for immediate attention to
314/726-3009 (IMs welcome).
Emergency Medicine — Outstanding opportuni-
ties in emergency medicine available in a
variety of Iowa and Minnesota locations for
primary care trained or experienced emer-
gency physician. Quality lifestyles in family
oriented communities. Guaranteed compensa-
tion, paid malpractice, health/dental, life,
disability. Send CV or call Sheila Jorgensen.
Emergency Practice Associates, P.O. Box
1260, Waterloo, Iowa 50704; 800/458-5003,
fax 319/236-3644.
336 Iowct Medicine Volume 85/ 8 August 1995
CLASSIFIED ADVERTISING
Floyd County
Memorial Hospital
Seeking quality primary care
trained or emergency medicine
physician to practice at FCMC.
• Regular part-time or moonlighting
opportunities
• Weeknights, 12-hour shifts
• Low to moderate volume
• Highly competitivecompensation
• Paid St. Paul malpractice
Send CV or contact
, Melissa J. Milliken, CMSC
\ ACUTE CARE , INC.
• PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
II Family Practice Physician — Rare opportunity
f for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
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Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
■ Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
Emergency Medicine
Administrative Opportunity
Ottumwa, Iowa
Exceptional opportunity for primary care
trained or experienced emergency physician.
• 19,000 Annual Volume
• 12-Hour Shifts
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Send CV or call Sheila Jorgensen
EMERGENCY PRACTICE ASSOCIATES
PO Box 1260, Waterloo, Iowa 50704
800/458-5003 or fax 319/236-3644
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
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information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
STORM LAKE, IOWA
Rural lakeside community provides unique
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Pritchard, Administrator, Buena Vista
Clinic, Box 742, Storm Lake, Iowa 50588;
collect 712/732-5012; fax 712/732-2538.
Family Practice — Prominent 300+ physician
group based in southwestern Wisconsin seeks
additional family physicians for established
clinics in Iowa and Wisconsin. Attractive
group practices offer a professional and
stimulating environment with shared coverage,
modern local hospitals, strong specialty
network and competitive compensation
package. Practice settings vary from scenic
college towns to a picturesque Mississippi
River community. For details, call Susan
Pierce at 1-800/243-4353.
Ambulatory Care
Clinic
Seeking quality physician to prac-
tice either part, full-time or moon-
lighting during residency.
• Primary care, urgent care, oc-
cupational and sports medicine
• Weekday, wee knight and week-
end shifts
• Paid St. Paul malpractice
• Excellent benefit/bonus packages
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE, INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Time For a Move?
BC/BE FP, IM, OB/GYN, PEDS
Our promise — We’ll save you valuable time by
calling every hospital, group and ad in your
desired market. You’ll know every job within
7 days. We track every community in the
country, including 2000+ rural locations. Cedar
Rapids, Des Moines, Quad Cities, Kansas City,
Boston, Chicago, Indianapolis, many more.
New openings daily — call now for details!
The Curare Group, Inc.
M-F 9am-8pm, Sat 1-5 pm EST.
800/880-2028, Fax 812/331-0659
Job #C133MJ
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for 82.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for S25 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85 / 8 August 1995 3 37
IowalMedicine
CLASSIFIED fl D V E R T I S I N G
Floyd Valley Hospital
u
a
s
Seeking quality primary care
trained or emergency medicine
physician to practice at FVH.
• 4300 average volume ER
• Medical director and staff posi -
tions
• Full-time, regular part-time and
moonlighting opportunities
• Weeknight, 12- hour shifts and
weekends
• Highly competitive salary
• Paid St. Paul malpractice
Send CV or contact
1 Melissa J. Milliken, CMSC
r; jgggggiTE
A ACUTE CARE, INC.
■ IDdboBBo'
Eh
* PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Dermatologists Wanted
6 immediate positions. Miami Beach and North
Florida, Minnesota, Georgia, California and Texas.
BE/BC required. Salary to $200k and negotiable.
Ob/gyn & Plastic Surgeon Wanted
Open your own practice in our Miami Beach,
Florida very successful multispecialty group. No
fees, just split overhead expenses. BE/BC and
Florida license required.
Fax or send CV or call Avionne Allen
Physician's Placement Management Group
1000 Blythwood Place, Suite C-199
Davenport, IA 52804
800/251-6937 or fax 800/289-9754
Family Practitioner • Internist
Want the best of
worlds?
Live and work in a rural community-yet have easy
access to the educational, cultural, shopping, and en-
tertainment opportunities of the big city. Enjoy all the
benefits that go with small-town living-good neigh-
bors, safe schools, affordable housing, abundant rec-
reational choices-and go to the city when you want!
St. Croix Falls, Wisconsin is located just over the
scenic St. Croix River from Taylors Falls, Minnesota and
within 45 minutes of the metropolitan Twin Cities. With
25,000 households within the clinic service area, River
Valley Medical Center is the region’s largest and most
diversified practice group-13 family practitioners, 2
internists, 2 general surgeons, 2 orthopedic surgeons
and a physician assistant. Clinic is attached to a 50-
bed acute care hospital with a wide range of services.
Guaranteed first -year salary with second-year part-
nership and excellent fringes.
Send detailed CV to -.
Cathy Kortas
River Valley Medical Center
208 S. Adams St.
St. Croix Falls, Wl 54024
338
Iowa Medicine
Volume 85/8 August 1 995
Exceptional Opportunity at
Blue Cross and Blue Shield
of Nebraska
We have an opening for a Chief Medical Officer,
preferably with an internal medicine or family prac-
tice background, to help develop and shape our
corporate medical policies.
Interested candidates should see themselves as lead-
ers, capable of interacting with our medical com-
munity as well as business leaders. We’re looking
for a physician with vision, business savvy, exten-
sive knowledge of current medical issues and alot of
energy.
Candidates must be licensed to practice medicine in
Nebraska (or be able to meet the requirements to
obtain a license in Nebraska). Managed Care Cer-
tification and/or experience is highly desirable.
Contact Micki Baldino, Sr. Vice President, Human
Resources, Omaha, Nebraska; 402/390-1813. We
are an equal opportunity employer M/F.
comprehensive and diverse
school system, and many amenities for an excellent quality of life. Madison, WI,
Dubuque, IA, and Rockford, IL, are just an hour away, while Chicago and Mil-
waukee are within an easy two-hour drive. When you’re thinking about a setting
for your professional practice and the “good life” for your family, give some thought
to Monroe.
Our town of 10,000 is home to The Monroe Clinic, the hub of healthcare in Mon-
roe. A consolidated and integrated healthcare facility including a 140-bed acute
care hospital with 24-hour ER coverage and an adjoining 114,000 sq. ft. state-of-
the-art clinic, The Monroe Clinic provides a full range of diagnostic and therapeu-
tic testing and treatment. We invite your participation in our 50+ physician
multispecialty group practice as a BC/BE physician in: FAMILY PRACTICE,
OUTPATIENT PSYCHIATRY, ORTHOPEDIC SURGERY, DERMATOLOGY,
AND EMERGENCY MEDICINE.
We offer productivity based pay with excellent 1st year income guarantee, free-
dom from office management and buy-in costs, and comprehensive benefits in-
cluding $3750 CME allowance. For more information, write or call: Physician
Staffing Specialist, THE MONROE CLINIC, 515 22nd Ave., Monroe, WI
53566. 800-373-2564. Or fax resume to: 608/328-8269. EOE.
r 'Lp
4 A L|J The Monroe Clinic
A proud caring tradition
SPECIALIZE IN
AIR FORCE MEDICINE.
Become the dedicated physician you
want to be while serving your country in
today’s Air Force. Discover the tremen-
dous benefits of Air Force medicine. Talk
to an Air Force medical program manag-
er about the quality lifestyle , quality
benefits and 30 days of vacation with pay
per year that are part of a medical career
with the Air Force. Find out how to quali-
fy. Call
USAF HEALTH PROFESSIONS
TOLL FREE
1-8Q0-423-USAF
Iowa[Medicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrev, MD, PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pcdiatrie and Adidt Allergy', PC
Veljko K. Zivkovich, MD
Robert A. Colnian, MI)
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Robert J. Barry, MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medieal Center, PC
Carey A. Itligard, MI), FAAD
James D. Bunker, MD, FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Bragc, Ml)
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gervich, MD
Daniel J. Schrocdcr, MD
Ravi K. Venturi, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MD, ABIM
Grace Z. Ang, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medieal Clinic Neurology
Andrew C. Peterson, Ml)
Laurence S. Krain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology \ EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medieal Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medieal Clinic
Neurosurgery'
James R. Lamorgcsc, MI)
Loren J. Moutv, MI)
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Ilosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery'
340 Iowa Medicine Volume 85/8 August 1 995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Ilavne, Ml)
Thomas A. Carlstrom, MI)
David J. lioariui. Ml)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MD
S. Randy Winston, MD
Douglas R. Koontz, MI)
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad D. Abernathey, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, MD
John M. Gracthcr, Ml)
Gilbert W. Harris, MD
James A. Davison, MD
Norman F. Wood lief, MD
Eric W. Bligard, MD
David D. Saggau, MD
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates. PC
Robert 1). Whinerv, MD
Stephen II. Wolken, MD
Robert B. Goffstcin, MI)
Lyse S. Strnad, MI)
John F. Slander, MI), PhD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6880
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MD
Randall S. Brcnton, MD
James L. Dummctt, MI)
Mick E. Vandcn Bosch, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MD
Marshall C. Grciman, MD
Steven R. Ilerwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Hill, MI)
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Iowa Orthopaedic Center, PC
Marvin II. Dubanskv, Ml)
Marshall Flapan, MI)
Sinesio Misol, MD
Joshua I). Kimclman, DO
Timothy G. Kenney, MD
Lynn M. Lindaman, MI)
Jeffrey M. Farbcr, MD
Kyle S. Galles, MD
Seott A. Meyer, MD
Cassini M. Igram, MD
Rodney E. Johnson, MI)
Martin S. Roscnfeld, DO
Donna J. Buhls, Ml)
Jill R. Meilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; S2.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85/8 August 1 995 341
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MI)
Eugene Peterson, MI)
Richard B. Merrick, MD
Peter V. Boesen, MD
Robert R. Updegraff, MD
3901 Ingersoll
I)es Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neck
Surgery, PC
Thomas J. Benda, Sr., MI)
James W. White, MI)
Craig C. Ilcrther, Ml)
Thomas J. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MD
Guy E. McFarland, MI)
Thomas F. Viner, MD
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Smits, MD, PC
1040 5th Avenue
lies Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Phillip A. Linquist, DO, PC
1000 Illinois
lies Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
Janies R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Perinatology
Des Moines Perinatal Center, PC
Neil T. Mandsager, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice I). Schnell, MI)
Earecduddin Ahmed, MI)
Arthur B. Scarlc, Ml)
Bogdan E. Krysztofiak, MD
Rehabilitation Medicine Associates
William I). dcGravelles, Jr., MD
Charles F. Dcnhart, MD
Marvin M. Hurd, MI)
William C. Koenig, Jr., MD
Karen Kicnkcr, MD
Todd C. Troll, MD
Lori A. Sapp, MD
Younkcr Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, Ml), FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Chest, Infectious Diseases St Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MD
Donald L. Burrows, MI)
Michael Witte, DO
Gerard A. Matvsik, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Pulmonary > Diseases
Surgery
Wendell Downing, Ml)
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warlick, Ml), FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Advertising Index
Bernie Lowe & Associates 312
Blue Cross Blue Shield of LA 310
Blue Cross Blue Shield of NE 339
Clarkson College 330
Dale Clark Prosthetics 343
IMS Services 306
Medical Records
Assistance Services 323
Medical Management
Strategies, PC 323, 328
Mercy Hospital 329
MMIC 344
Monroe Clinic 339
River Valley Medical Center 338
U S. Air Force 339
342 Iowa Medicine Volume 85 / 8 August 1995
Iowa I Medicine
THE PRESIDENT COMMENTS
The corporatization
of health care
A few weeks ago at the suggestion of a
friend, I read an editorial titled, “Man-
aged Care and the Morality of the Mar-
ketplace” ( NEJM , July 6, 1995). I assumed
the author — Dr. Kassirer — is from the Boston
area, where the influence of HMOs, managed
care organizations and large insurance com-
panies is greater than in other parts of the
country. His concerns, however, apply to all
physicians. Unfortunately, the key motiva-
tion of some large insurance companies and
corporations is not the care of the patient
but the financial health of the business enti-
ty-
Should health care be subjected to the val-
ues of the marketplace? This could be the
fundamental question for those of us in med-
icine.
Market-driven health care ulti-
mately creates conflict that
threatens our professionalism,
says Dr. Kassirer. Doctors are
expected to do all they can to help
patients, using the best available
tests and treatment. On the other
hand, there is constant pressure
to cut costs and limit services. As this sce-
nario is played out, the doctor ultimately
may be forced to chose between the best
interest of the patient and their own eco-
nomic survival.
In his article, Dr. Kassirer makes some
assumptions: 1) Cost and not quality will
dominate in the marketplace because quality
is much more difficult to measure than cost;
2) All plans will offer fewer services and even
the best will trim benefits; and 3) Physicians
(who else?) will be given the responsibility to
implement these restrictions. This pits their
duty to their patients against their duty to
the payer or the employer. Once again we
see the basis of the argument against the
practice of medicine by a non-medical corpo-
ration. That battle appears to be lost.
This also points out the importance of
physicians’ participation in the formulation
of policy used by various health care organi-
zations.
I have no doubt that greater efficiencies
can be found and implemented in the deliv-
ery of health care. While market distribution
may work well for many goods and services, I
don’t believe that health care is a
commodity and that the corporati-
zation of health care is appropri-
ate.
Physicians have a professional
and moral responsibility to care
for their patients. When patients
are ill, they are vulnerable and
looking for help. The patient
needs to know that the doctor is on their side
and that his or her concern for patients will
override any financial consideration.
As Dr. Kassirer says, “After all, what oath,
promise or pledge did we ever make either as
an individual or as a professional that oblig-
ates us to restrict care? We pledged instead
to provide care.” O
This pits
their duty
to their patients
against their duty
to the payer or
the employer.
Joseph Hall, MD
Iowa Medicine Volume 85/9 September 1 995 351
Iowa [Medicine^
IMS Update
AT A GLANCE
The Mahaska County
Medical Society Alliance
continues its campaign
to stop teenage preg-
nancy with distribution
of the “Baby Think It
Over” doll. The doll,
which will not stop cry-
ing until it is picked up
and “fed” with a feeding
plug, can be purchased
for 8250 and donated to
an Iowa school. For
more information, call
Karen Messamer, IMSA
president-elect, at 515/
673-3751.
•
A new study in New
Orleans shows that
poverty — not race —
accounts for the sharply
higher incidence of
domestic homicide
among blacks. The
study, published in
JAMA, found that the
sixfold difference in
black and white rates of
domestic homicide dis-
appeared when house-
hold crowding was
used as a measure of
socioeconomic status.
National violence conference registration
Any physician or other health care profes-
sional can register now for “Bridging Science
and Program”, a national violence prevention
conference scheduled for October 22-25 at
the Des Moines Convention Center.
The conference will bring together scien-
tists and practitioners who work toward vio-
lence prevention in family and intimate vio-
lence, youth violence, workplace violence
and suicide prevention. Between 500 and
800 participants from across the country are
expected, including Vice President A1 Gore.
Registration is 850. For more information,
call the national conference organizers at
404/488-4647 or fax 404/488-4349.
Career satisfaction survey
Fifty-five percent of physicians would
choose their profession again, according to
the results of a University of Northern Iowa
survey. The survey compared career satisfac-
tion rates of physicians, dentists and teachers.
According to the survey, 32% of physicians
would not choose their profession again. The
remaining 13% were undecided.
In addition, 32% of physicians said they
would encourage their children to pursue a
career as a physician; 50% would not.
Free materials on several subjects
Healthy babies — The Iowa Substance
Abuse Information Center has available a
video entitled “I’m Having a Baby” available
for physician offices. The video was filmed in
Iowa and features local experts as well as the
adoptive mother of two crack babies.
To order a complimentary copy, call
800/237-0614.
Flu shots — The Health Care Financing
Administration has embarked on a campaign
to educate Medicare beneficiaries about the
value of Hu shots. As part of the campaign,
patient brochures are available by calling
HCFA’s regional office at 816/426-6317.
Violence — The AMA Alliance has pub-
lished a program kit for its nationwide anti-
violence campaign. The 52-page packet out-
lines how to plan and implement many types
of anti-violence events. To receive a program
kit, call the AMA Alliance at 312/464-4470.
IMS dues statements
The first Iowa Medical Society dues state-
ments will go out in early October. Iowa is
unified at the state and county levels. Prompt
payment of your dues will be greatly appreci-
ated. IE1
Specialty Society Update
The American College of Cardiology, Iowa Chapter,
will hold its annual meeting September 16, 10
a.m. to 4 p.m., in Iowa City.
The IMGMA Fall Meeting will be September 13-15
at the Village East in Lake Okoboji.
The Iowa Psychiatric Society Executive Council
recently discussed the need to raise annual IPS
dues. Significant advocacy in the new managed
care environment this past year has necessitated
legal work and greater involvement with third party
payers. Also, Medco has announced that a new
outpatient treatment request form is now available
on diskette. Call Medco, 515/223-0306.
The Iowa Association of County Medical Examiners
Board of Directors met July 21 to make plans for
their fall meeting on Friday, November 3 at the
Sheraton Inn in Cedar Rapids. At the meeting, Dr.
RC Wooters, Polk County medical examiner emeri-
tus, will be honored. The next I ACME Board meet-
ing will be September 29 at the IMS.
The Iowa Oncology Society annual meeting will be
October 27 at the McFarland Clinic in Ames.
The Iowa Association of Pathologists will meet in
conjunction with the annual Iowa Anatomic
Pathology course on September 15 and 16 in con-
junction with the Ul College of Medicine. The meet-
ing will be at the Iowa City Holiday Inn.
352 Iowa Medicine Volume 85/9 September 1 995
CURRENT ISSUES
Focus on IMS Alliance
In June I had the privilege of attending the AMA
Alliance Annual Meeting at the Drake Hotel. The
Alliance is moving forward on SAVE Today (Stop
America’s Violence Everywhere) which will be held
annually on the second Wednesday of October,
beginning October 11, 1995.
Every Medical Alliance in the nation is urged to
do something on that day to focus attention on this
devastating social problem that robs so many
Americans of quality living.
Our project in Iowa is in the planning stages. If
you have any projects you would like to suggest or
worthy organizations for us to contact for help,
please call us at the Iowa Medical Society head-
quarters, 1-800/747-3070. At the Alliance’s July
summer board meeting the enthusiasm throughout
the state was wonderful.
Please help us with this worthy project as you
hear about it in your office and through the media in
the coming months.
Contributed by Linda Miller, president, IMSA
CLARKSON MEDICAL
LECTURE SERIES
November 17, 1995
8:00 a.m. - 5:00 p.m.
Advances in
Primary Care:
Building on the
Legacy
Clarkson Hospital
Omaha, Nebraska
(Storz Pavillion)
For more information call
1-800/647-5500, ext 3039
402/552-3039
Watch your mail
for a special
patient information
sheet on Medicare
developed by the
Sowa Medical
Society,
Introducing A Bill That
Actually Gets Smaller Over Time.
Yxirs.
The older your receivables
get, the less they’re worth.
Between 90 and 180 days, the value of past due
receivables decreases Vi % every day.
And, at 180 days, your receivables are worth one
third of the original value. That’s only 33' on
the dollar.
Don’t wait to collect what’s yours. Put I.C. System
to work for you. We’re endorsed for debt collection
services by more than 1,000 business and professional
associations nationwide, including yours.
Call I.C. System today. Before your money
1-800-325-6884
(O.
IOWA MEDICAL SOCIETY
I.C. SYSTEM
Imcin Medicine Volume 85 / 9 8entemher 1995
Iowa [Medicine
Futures
AT A GLANCE
Mutual of Omaha of
South Dakota , in con-
junction with a hospital
and two physician clin-
ics, recently launched
the state’s second major
HMO. It covers 1,000
lives in Sioux Falls and
plans to cover 5,000 by
the end of 1995. The
HMO’s primary compe-
tition is DakotaCare, the
HMO sponsored by the
state medical society.
According to a recent
edition of CBS News
“Eye On America”, HMO
executives are paid
nearly twice the average
of CEOs in companies of
comparable size. Nor-
man Payson, Health-
Source CEO, is the high-
est paid HMO executive,
earning SI 5 million last
year. None of the top-
earning CEOs whose
salaries were discussed
agreed to be interviewed
by CBS.
Managed care legislation in California
Several pieces of legislation aimed at regu-
lating the managed care industry in
California are awaiting California Senate
approval. These bills have the support of the
California Medical Association.
If enacted, the bills would require health
plans to provide more coverage for experi-
mental treatments, force managed care net-
works to admit additional doctors at patients’
requests and and expand the liability of man-
aged care and utilization review organiza-
tions. Political observers say there is a defi-
nite anti-managed care mood among
California lawmakers.
Incremental reform has life
There are several indications that efforts
are not dead to move incremental health
reform forward this Congress. Nancy
Kassebaum, Senate Labor Committee chair,
along with Ted Kennedy and 10 other Labor
Committee members, have introduced a
“consensus” incremental bill.
The bill would limit exclusions for preex-
isting conditions, guarantee availability and
renewability, increase purchasing clout of
individuals and small employers and provide
for state flexibility to enact reforms providing
additional consumer protection.
According to a recent Wall Street Journal
editorial, President Clinton has also boosted
the odds that some moderate health care
changes may be enacted this year.
The president has accomplished this, said
the Journal, “by drastically lowering his
sights on overhauling health care and tucking
his proposal into the big budget envelope”.
The proposals put forth by the president
would help small businesses afford insurance,
provide subsidies for family breadwinners
who lose their job and bar insurers from
denying coverage to people with preexisting
health problems.
Rep. Pete Stark of California was highly
critical of the president’s proposal. “I think it
sucks. It’s less than the Republican plans he
was attacking last year.”
The president’s bill also contains another
round of cuts in Medicare reimbursement for
physicians. This proposal has been criticized
by the AMA, though more diplomatically.
Going directly to physicians
Minnesota’s Business Health Care Action
Group is planning to begin direct contracting
with physicians and hospitals in 1997.
The group has contained health costs
among 24 member companies by encourag-
ing competition among plans. In 1994, the
firms averaged a 3.6% growth in health costs
compared to a national average of over 7%. EH
PHO CASE STUDY REPORT AVAILABLE FROM MICHIGAN STATE MEDICAL SOCIETY
A PHO case study report of nine physician organi-
zations around the US is available from the Michigan
State Medical Society. The case study report was
developed by the MSMS, the AMA and the Indiana
State Medical Association.
The report examines many issues concerning P0
development and operations, including how much
money is needed to capitalize a P0, how to engender
physician commitment, whether primary care-only or
specialist-only POs are viable and key elements of an
effective management system.
To order a copy of the report, call (517) 336-7594
or write to the Michigan State Medical Society, Attn:
Shannon Stockwell, 120 West Saginaw, PO Box 950,
East Lansing, Ml 48826-0950.
The cost of the report is $25 for AMA members and
$95 for nonmembers. Visa and Mastercard will be
accepted.
354 Iowa Medicine Volume. SS / 9 Se.ntem.her 7995
H i How to Collect for Control
i An advanced training seminar designed to improve
your success in preventing and collecting medical
— accounts receivable.
October 3 October 4 October 5
Omaha, Nebraska
Red Lion Inn
1616 Dodge Street
Des Moines, Iowa
Best Western International
Terrace Room #4
1810 Army Post Road
Cedar Rapids, Iowa
St. Luke’s Hospital
Medical Office Plaza
Rooms 2 & 3
£ A patient arrives on Friday afternoon with an “emergency. ” This patient’s account has already been sent to a collection
agency because all efforts to collect have failed. How do you treat this person? What if it were a new account? A good
customer?
Q A divorced mother brings her child for services and asks you to bill the father for treatment. What if the accompanying
* parent is the custodial parent? Who is responsible for payment of the services? Should you request a copy of the
divorce decree?
^ The insurance company has sent the payment for services to the patient rather than your office. How do you get the
* check? What if the payment is for a lesser amount and it states that your fees are UGR? What if you have a contract
with that insurance agency?
Do you know the answers to these questions? If not, you could be at risk for violation of the law — and fail to collect
payment for the services you have provided. It is important to understand the legal limits of your position, how and when
to finalize your accounts receivable and how to manage a healthy cash flow from your office.
IN ONE DAY WE WILL SHOW YOU HOW TO:
Control Systems
♦ Build a complete collection system
♦ Design an internal and external plan that works
Preventative Steps
♦
♦
♦
♦
♦
to Eliminate Collection Problems
Create an effective financial policy for a sound foundation
Utilize your best sources of information
Identify potential problem payers
Collect from insurance companies and attorneys quicker and with greater results
Design collection letters with third-party influence
Effective Collection Call Planning
♦ Script your calls for greater effectiveness
♦ Set objectives before each call
♦ Choose specific words for the greatest effect
♦ Identify sources to obtain payment in full
Collection Calls for
♦
♦
♦
♦
♦
Control that Produce Results
Handle stalls and objections more creatively
Influence others to make and keep payment commitments
Collect with third-party influence
Stay in control of the telephone call
Know how and when to finalize delinquent accounts
FACULTY
JEFF STAADS is a nationally known consultant and trainer, with extensive experience
in health care operations and management. He is a master of collections, a motivational trainer
and an instructor of collection strategies. As President of The Business Resource Center (BRC)
for the past five years, Mr. Staads has developed the company’s training and consulting programs.
BRC provides both consultation and seminars for leadership/management, personal skills
development and business/association development.
The professional associations for whom he has provided training and development
programs include: American Academy of Dental Group Practice, American Association of
Medical Assistants, Arizona Medical Association, Detroit District Dental Society, Indiana Dental
Association, Kimberly Quality Care, Medical-Dental-Hospital Bureaus of America, Metro Omaha
Medical Society, Oregon Society of Medical Assistants, Southern Medical Association, Special-
ized Pharmacy, State Medical Society of Wisconsin, Tennessee Medical Association, Texas Hospital Association, Washington
State Dental Association, the Yankee Dental Congress and the Wisconsin Clinic Credit Managers Association.
Mr. Staads is adept and knowledgeable with the many facets of collecting including patients and third-party insurers.
In addition, he has the ability to motivate managers and staff to be enthusiastic about collections and to improve their self-
concept with practical tools that ensure success. Mr. Staads combines humor with expertise in this one-day workshop to
improve the prevention and collection of your receivables.
“I was certainly impressed with your
dynamic presentation style and ability to
keep the audience interested and involved
throughout the entire day. Participants
appeared ‘charged up’ and excited about
going back to their jobs to implement
your ideas and suggestions. ”
Karen Garrett, director of practice
management training
State Medical Society of Wisconsin
“Excellent program and speaker — I en-
joyed it immensely while learning prac-
tical suggestions and new procedures. ”
Diane Marshall, GMA, office manager
Des Moines
Cost: $150 for IMS member or staff; $240 for non-member or staff (includes lunch)
★ This program is part of the IMS Medical Business Specialist (MBS) Certificate Program.
How To Collect For Control
Registration Form
NAME(S):
CLINIC/PRACTICE NAME:
ADDRESS:
PHONE: FAX:
AMOUNT ENCLOSED: SPECIFY DATE/LOCATION:
Please make checks payable to IMS Services. Mail check and registration form to:
IMS Services, ATTN: Sherry Johnson, 1001 Grand Avenue, West Des Moines, LA 50265-3599.
CURRENT ISSUES
C H M I S Update
As part of the Iowa Medical Society’s ongoing effort to educate Iowa physicians about the
Community Health Management Information System (CHMIS), this CHMIS Update page will be a
regular feature in Iowa Medicine.
Steady progress continues toward the
July 1, 1996 implementation date for the
Community Health Management Infor-
mation System (CHMIS). The CHMIS
Governing Board met July 21 and received
the following updates from advisory com-
mittees considering various aspects of
CHMIS implementation:
Quality Review — The final draft of the
data dictionary was presented and ap-
proved by the Governing Board. This is an
evolving document which defines data ele-
ments to be captured by the data reposito-
ry. The document also defines the origin of
the data elements (specific boxes on the
HCFA 1500, the UB 92, remittance advice,
etc.). The Governing Board approved the
advisory committee recommendation that
all providers and payers adhere to the fed-
eral coding guidelines with respect to V-
codes.
Data — This advisory committee has
appointed three task forces to resolve spe-
cific issues — 1 ) definition of the data ele-
ments to be collected by the data reposito-
ry for retail pharmacy claims; 2) design of
patient satisfaction and health status sur-
veys; and 3) standard reports to be distrib-
uted from the CHMIS data repository.
Since the Governing Board has decided
it will not release patient or provider-spe-
cific reports, one task force recommends
that providers and payers have the ability
to review their data in the data repository
prior to release or sale of the data. This will
ensure accuracy of the data. Other third
parties may purchase the data base to
produce provider-specific reports. The
Governing Board approved the inclusion of
worker’s compensation information from
the insurance claim form.
Technical — CHMIS networks will col-
lect data to be fed into the data repository.
The task force developing network certifi-
cation criteria received a slight setback.
The group had been revising national stan-
dards from the Electronic Healthcare
Network Accreditation Commission
(EHNAC), adapting them to conform to
specific Iowa CHMIS requirements.
EHNAC now says they do not want their
standards revised. As a result, CHMIS will
use the original EHNAC standards as the
first step in a network certification process,
then mandate additional criteria for certifi-
cation as an Iowa CHMIS network.
Another task force is developing a
Request For Proposal (RFP) for vendors to
bid on the data repository. This RFP is
expected to be approved this month by the
Governing Board. Vendors will likely have
60 days to submit bids. A contract proba-
bly won’t be awarded before mid-December
at the earliest.
The Governing Board has decided that
social security numbers will be used to
track and match patient data in the repos-
itory.
Committee appointments — Bonnie
Steege, an employee of John Deere
Waterloo Works, has been appointed to fill
one of two vacant seats on the CHMIS
Governing Board.
The IMS is seeking physicians who are
interested in serving on advisory commit-
tees as vacancies occur. Contact Ed
Whitver of the IMS staff if you are interest-
ed. IMS physicians involved in the CHMIS
process continue to advocate key issues
from the IMS statement of policy on
CHMIS. Current discussions involve elec-
tronic insurance eligibility verification,
time frame for other providers to begin
CHMIS participation and universal accep-
tance of V-codes.
Because there is currently no CHMIS
newsletter, the best way to stay informed
on CHMIS developments is to read this
monthly CHMIS update page in Iowa
Medicine.
YOUR representatives
on state CHMIS
committees:
CHSV11S
Governing Board:
Dale Andringa, MD
Des Moines
515/241-4102
Beth Bruening, MD
Sioux City
712/233-i529
CHSV1SS advisory
committees:
Communications/
Education
Laine Dvorak, MD
Data Advisory
William Bonney, MD
John Brinkman, MD
Ethics/Confidentiality
Charles Jons, MD
Quality Review
Elie Saikaly, MD
William Langley, MD
Teehnical Advisory
Mark Purtle, MD
IMS CHMIS
Committee:
Terrence Briggs, MD (chair)
IMS staff:
Ed Whitver
Barb Heck
Dean Gillaspey
Iowa Medicine Volume 85/9 September 1 995 355
Iowa [Medicine
Legislative Affairs
AT A GLANCE
In a recent interview,
James Todd, MD, AMA
executive vice presi-
dent, criticized one
aspect of President
Clinton ’s proposed
health care policy. Dr.
Todd said the presi-
dent's plan to balance
the budget by sharply
restricting Med-icare
payments to doctors,
hospitals and nursing
homes is un-sound
because there is no
“shared sacrifice”.
•
Washington insiders
say the president will
veto some of the 13
spending bills to protest
cuts in appropriations
for certain programs. In
some cases, the GOP
won’t have the two-
thirds votes necessary
to override a veto, so
there will be more deal-
making and a massive
spending/tax package
around Thanksgiving.
The deal will sharply
slow the growth of fed-
eral spending over the
next seven years.
IMS preparing for 1996 Legislature
The IMS Committee on Legislation will
meet September 12 and November 28 to dis-
cuss recommendations for 1996 legislative
priorities. The committee’s recommenda-
tions will go to the IMS Board of Trustees for
final approval.
Specialty societies are encouraged to bring
issues of concern to the committee’s atten-
tion through their representatives on the
committee. IMS members may also contact
Kevin Cunningham, MD, committee chair;
Clarence Denser Jr., MD, vice chair or Becky
Roorda, IMS staff.
IMS Committee on Legislation
Kevin Cunningham, MD, chair
Clarence Denser, Jr., MD, vice chair
Ralph Beckett, MD, thoracic society
Christopher Blodi, MD, ophthalmology
John Canady, MD, plastic surgery
David Carlyle, MD, family practice
David Coster, MD, general surgery
William de Gravelles, MD, rehabilitation medicine
Judith Dillman, MD, anesthesiology
Steve Eyanson, MD, internal medicine (ACP)
Tom Gellhaus, MD, obstetrics/gynecology
Robert Gitehell, MD, orthopedic surgery
Jerry Lewis, MD, psychiatry
Edward Loeb, MD, pathology
Dean Lyons, MD, otolaryngology
Randall Maharry, MD, dermatology
Dennis Mallory, DO, county medical examiners
Roscoe Morton, MD, oncology
Edward Nassif, MD, allergy
Richard Nelson, MD, UI College of Medicine
Steven Phillips, MD cardiology
Kenneth Schultheis, DO, emergency medicine
Rizwan Shah, MD pediatrics
John Shierholz, MD radiology
Paul Sosnouski,MD, internal medicine (ASIM)
Kent Svestka, MD, family practice
Steven Wolfe, MD, family practice
Pam Smits, IMS Alliance
Pat Buelow, Iowa Medical Group Management
Association
Pharmacist drug therapy management
The Iowa Board of Pharmacy Examiners
has proposed administrative rules to allow
pharmacists to provide drug therapy manage-
ment, including initiation of drug therapy and
therapeutic interchange, under protocol or
guidelines from a prescribing practitioner.
The IMS has submitted comments oppos-
CONTRACT WITH AMERICA SCORECARD AND OUTLOOK
A recent Kiplinger Newsletter contained the following scorecard of the status and pos-
sible outcome of initiatives contained in the Republican Contract with America.
Proposal
House
Senate
Outlook
Property rights compensation
Passed
Pending
Probably won’t make it
Regulatory reforms
Passed
Pending
Watered down, if anything
Tax cuts
Passed
Pending
Probably modest cuts
Welfare reform
Passed
Pending
Still up in the air
Crime bill
Passed
Pending
Probably will pass
Product-liability limits
Passed
Passed
Might die in conference
Line-item veto
Passed
Passed
Will be delayed awhile
Balanced budget amendment
Passed
Defeated
Maybe next year
Congressional reforms
Passed
Passed
Signed into law
Curbs on unfunded mandates
Passed
Passed
Signed into law
Term limits amendment
Defeated
No action
Forget about it
356 Iowa Medicine Volume 85 / 9 September 1995
CURRENT ISSUES
ing the rules as drafted because they would
have the effect of allowing pharmacists to
practice medicine and physicians do not
have the legal authority to delegate such
activities to individuals not under their direct
supervision.
The Board of Pharmacy Examiners does
not regulate physicians. The Iowa State
Board of Medical Examiners would be
responsible for determining whether such
authority could he delegated by physicians.
The Iowa Administrative Rules Review
Committee has requested an attorney gener-
al’s opinion on whether the Board of
Pharmacy Examiners has the legal authority
to make such a major change in practice
through the administrative rules process
rather than through legislation.
While such opinions are not legally bind-
ing, the attorney general functions as legal
counsel for state agencies; failure to follow
legal counsel’s advice would occur only in
highly unusual circumstances.
IMS/AMA policy states that the practice of
therapeutic interchange is acceptable only in
inpatient hospitals and selected similarly
organized outpatient settings that have an
organized medical staff and a functioning
pharmacy and therapeutics committee.
The system must: 1) have the concurrence
of the organized medical staff; 2 ) provide
detailed methods and criteria for the selec-
tion and objective evaluation of pharmaceu-
ticals to be used; 3) have policies for contin-
uous and comprehensive review of the drugs
which may be substituted; 4)provide a
method to monitor compliance with the pro-
tocol and clinical outcomes where substitu-
tion has occurred and to intercede where
indicated and; 5) provide a mechanism that
allows the prescribing physician to override
the system when necessary for an individual
patient without inappropriate administrative
burden.
The IMS plans to discuss the issue with
representatives of the Iowa Pharmacists
Association to determine if there is a way to
facilitate communication between physicians
and pharmacists in caring for patients.
Gall Becky Roorda at IMS, 515/223-1401
or 800/747-3070, for more information. E]
Mercy-Harvard Executive Program
in Health Policy and Management
Fourth Annual
An advanced management program for physicians and
health care executives designed to prepare Iowa’s health
care leaders for the future. Each day-long session is pre-
sented by faculty members from the Harvard School of
Public Health.
Sessions
• The Changing Health Care Organization
• Biostatistical Methods in Medicine
• Allocation of Health Care Resources
• Health Law and Risk Management
• Health Care Information Systems
• Health Care Policy: Development, Passage,
Implementation
1996 Dates
January 19 March 15 May 17
February 16 April 19 June 14
Fridays ( 8:30 a.m. -4 p.m.)
Who should attend
Physicians • Health Care Administrators
Lawyers • Nurses • Insurance Executives
Human Resource Managers
CME’s/CEU’s offered
For a brochure call: 515-222-7255
VMERCY
400 University Ave. • Des Moines, Iowa 50314
Iowa Medicine Volume 85 / 9 September 1995 3 57
Iowa | Medicine
Medical Economics
AT A GLANCE
Watch your mail for
materials provided by
the Iowa Medical Soc-
iety for physicians
whose patients are con-
fused about Medicare
reform. The IMS has
created a one-page Q &
A piece (suitable for
copying) which is
geared for patients and
discusses basic Medi-
care issues. A synopsis
of the AMA’s Medicare
proposals will also be
sent to IMS members.
A recent survey by the
Iowa Department of
Public Health shows
childhood immuniza-
tion rates in Iowa have
significantly increased.
The survey shows that
77% of two-year-olds are
fully immunized, up
from 50% reported in
1993.
Obstetrical stays — IMS, AMA policy
Members of the IMS Committee on
Maternal and Child Health plan to discuss the
issue of how long women should stay in the
hospital following vaginal and C-section
births.
Major insurers including two in Iowa
announced plans to limit payment for hospi-
talization after normal delivery of a baby to
24 hours unless additional time is approved,
causing a major dap in the media and wide-
spread public criticism.
In the wake of these announcements, a bill
was introduced in the US Senate requiring
health insurers to allow mothers and new-
borns to stay in the hospital at least 48 hours
after delivery.
Meanwhile, in the Des Moines Register, a
spokesperson for Principal Health Care of
Iowa said that company will delay until
January 1 any changes in the number of
obstetrical days. Principal had planned to
implement hospital stay limits for new moth-
ers on August 1.
Delegates to the AMA House of Delegates
this June approved a new policy regarding
postpartum hospital stays. The new policy
expresses concern that there is an absence of
data to demonstrate that brief perinatal hos-
pital stays are safe for babies and mothers.
The delegates said that the length of stay
should be determined by the clinical judg-
ment of attending physicians.
The AMA has not called for legislation to
mandate payment for a specific length of stay
due to concerns that such laws legislate the
practice of medicine.
This issue will be discussed by the IMS
Committee on Maternal and Child Health.
The IMS will participate in a study of the
issue by the Infant Mortality Review Panel led
by Herman Hein, MD. Dr. Hein is a member of
the IMS Committee on Maternal and Child
Health and a nationally-renowned expert on
infant mortality.
Blue Cross Blue Shield has indicated they
will be flexible in implementing payment pol-
icy, will rely heavily on the clinical judgment
of physicians who recommend longer stays
for patients and will pay for a home visit after
discharge.
The IMS plans to discuss these issues fur-
ther with Principal and other payers.
Fee schedule adjustment
HCFA has decided to achieve budget neu-
trality in the Medicare fee schedule by
adjusting the conversion factor rather than
the relative value units. HCFA hopes to begin
using the CFs January 1, 1996 as part of its
fee schedule proposals.
The adjustment will mean little difference
in physician reimbursement.
To date, HCFA has simply trimmed all
RVUs across the board to achieve budget
neutrality requirements. Groups such as
AMA and the PPRC asked HCFA to use the
conversion factor in order to maintain the
integrity of the system. Until this year, HCFA
said it lacked authority to do so.
Other proposed Medicare payment and
policy changes for 1996 were published in
the Federal Register. To comment on the pro-
posed changes, mail written comments (one
original and three copies) to: HCFA, Dept, of
Health and Human Services, Attn: BPD-827-
P, PO Box 7519, Baltimore, MD 21207-0519.
Comments must be received by September
25, 1995.
Hospitals win Minnesota tax litigation
Hospital associations in Iowa, North
Dakota, South Dakota and Wisconsin have
been notified that a court ruling regarding
the MinnesotaCare tax has gone in their
favor. A lawsuit filed by the AMA and the IMS
on behalf of physicians in states bordering
Minnesota was also successful.
358 Iowa Medicine Volume 85/ 9 September 1995
CURRENT ISSUES
The state of Minnesota is now permanent-
ly barred from collecting the MinnesotaCare
tax from either hospitals or physicians which
treat Minnesota patients.
Court rules for AMA, medical societies
A federal court has ruled in favor of AMA,
the Medical Society of New York and three
county societies in New York in an antitrust
suit filed by a group of chiropractors.
The suit, filed in 1993, charged that the
medical organizations, several IIMOs and the
Health Insurance Association of America had
conspired to block chiropractors’ access to
managed care plans.
A US District Court judge threw out all the
claims against the medical societies and
denied the plaintiffs permission to replead
their case. The court declined to dismiss the
claims against the IIMOs and the IIIAA.
The judge termed “ludicrous” the chiro-
practors’ claim that the AMA had monopo-
lized the market for medical information. E3
Franciscan Skemp
Healthcare
MAYO HEALTH SYSTEM
La Crosse, Wisconsin- Exciting opportunities are
available for BE/BC physicians in the following areas:
• Family Practice • Urgent Care • Pulmonology
• Cardiology • Neurology • Neurosurgery
• Orthopedics • Neonatology
• Emergency Medicine
Franciscan Skemp Healthcare, an integrated delivery
network, serves a population base of 350, 000. We
include three hospitals and 12 clinics with over 100
active medical staff members.
La Crosse is located in scenic Mississippi River bluff
country with excellent fishing, hunting, boating. Ideal
family-oriented environment. Good public and private
schools.
Contact:
Tim Skinner, M.S.Ed., or Bonnie Nulf
Franciscan Skemp Healthcare
800 West Avenue South
La Crosse, WI 54601
Phone: (800) 269-1986
Fax: (608) 791-9898
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♦
\ $30,000 BONUS OFFERED TO HEALTH CARE PROFESSIONALS
is
If you are a board-certified physician or a candidate for
board certification in one of the following specialties,
you may qualify for a bonus of up to $30,000 in the Army
Reserve.
Anesthesiology
General Surgery
Thoracic Surgery
Pediatric Surgery
Orthopedic Surgery
Colon-Rectal Surgery
Vascular Surgery
Neurosurgery
A test program is being conducted which offers a bonus
to eligible physicians who reside in certain geographic
areas (Pennsylvania, West Virginia, Ohio, Michigan,
Illinois, Indiana, Wisconsin, Minnesota and Iowa) . You
would receive a $10,000 bonus for each year you serve
as an Army Reserve physician — for a maximum of three
years.
You may serve near your home, at times convenient for
you, or at Army medical facilities in the United States
and abroad. There are also opportunities to attend con-
ferences and participate in special training programs,
such as the Advanced Trauma Life Support Course.
To learn more about the Army Reserve and the Bonus
Test Program, call one of our experienced Medical
Personnel Counselors:
Call Collect:
CPT Rick Otto 612-854-7702
ARMY RESERVE. BE ALL YOU CAN BE.
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Iowa Medicine Volume S5 / 9 September I ‘>05 359
♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦
Iowa 1 Medicine
Practice Management
AT A GLANCE
Be careful what you ask
job applicants — you
might run afoul of
EEOC , which enforces
the disabilities law. You
can’t ask if an applicant
has AIDS, has ever filed
a workers’ comp claim,
is on medication or has
been treated for sub-
stance abuse or depres-
sion. However, it is okay
to ask about perfor-
mance and whether
they can handle tasks
that are essential to
doing the job.
•
OSHA will hound com-
panies with bad safety
records under a pro-
gram that will go
nationwide in 1 996.
Regulators will use
workers’ comp records
and other data to spot
the worst offenders.
However, there will be
fewer inspections of
companies with clean
records.
IRS crackdown on mismatched ID numbers
Federal law requires that a 1099-MISC
form be filed for each person or corporation
to whom an entity paid at least S600 in med-
ical payments. The doctor’s name and
Taxpayer Identification Number (TIN) must
be on the 1900-MISC form when it is submit-
ted to the IRS.
The IRS implemented a TIN verification
system for doctors because of mismatches
with doctor names and TINs. Mismatches
occur for reasons including: affiliated doctors
or clinics use the same TIN; practice groups
use one TIN for multiple sites with different
names; inconsistent use of TINs between
group practice and individual practice; incon-
sistent use of abbreviations for names.
Under the IRS TIN verification system, the
IRS requests employers and other payers to
correct doctor taxpayer ID numbers that
appear on the 1099-MISC forms. Employers
do this by sending an IRS form and an IRS
letter to the doctor. If an employer receives a
second notice from the IRS on the same doc-
tor within a three-year period, employers
must mail the notice directly to the doctor
and begin withholding 31% of all future pay-
ments to that doctor.
Employers may not stop withholding from
reimbursements until the IRS says the doctor
lias provided a correct TIN. Doctors should he
sure to respond to any TIN inquiries to be sure
the correct information is in the system.
More waived tests under CLIA revisions
Admitting it is unlikely that the Clinical
Laboratory Improvement Amendments
(CLIA) will stay in place with no changes,
IICFA has put forth a four-point proposal to
revamp CLIA. However, it may not be
enough to satisfy congressional Republicans
who hope to erase the law from the books.
The CLIA plan is one of six regulations
IICFA found in need of change in response to
President Clinton’s call for agencies to rein-
vent health care regulations. Following are
the four changes IICFA proposes:
• Expand the waiver criteria and stream-
line the waiver process to waive more tests.
Requirements would be waived for tests that
do not require trained personnel. (Proposed
rule published this month.)
• Waive the routine two-year survey of
“black box” technology users; conduct sur-
veys only if a problem is indicated. IICFA will
develop the criteria to determine which tech-
nologies qualify for the waiver. (Proposed
rule to be published this month.)
• Use performance standards and require
less frequent on-site inspections of “excellent
performers”. Private accrediting organiza-
tions may be approved to accredit labs when
their standards meet CLIA’s. Also, IICFA pro-
poses to exempt labs if they are in states with
requirements that meet or exceed CLIA.
(Proposed rule to be published March, 1996.)
• LTse proficiency testing failures for educa-
tion and as an outcome indicator in laborato-
ry quality. Sanctions would be imposed only
in cases of “immediate jeopardy” or when the
lab has refused to correct the problem.
(Proposed rule to be published March, 1996.)
A spokesperson from the American
Clinical Laboratory Association said the
IICFA proposals are a positive first step, but
predicted plenty of discussion with IICFA,
physicians and others before further changes
are made in CLIA. Hi]
Upcoming IMS Services seminars
Collect for Control — Billing & Collection
Strategies
Tuesday, Oct. 3, Omaha • Red Lion Inn
Wednesday, Oct. 4, Des Moines • Best Western
(Airport)
Thursday, Oct. 5, Cedar Rapids • St. Luke’s
Medical Center
For more information on any seminar, call Sherry
Johnson at the IMS, 515/223-1401 or 800/728-5398.
360 Iowa Medicine Volume 85 / 9 September 1995
CURRENT ISSUES
Midwest Medical Insurance Company Focus on Risk Management
Failure to diagnose breast cancer
Delay in diagnosing breast cancer accounts for more medical malpractice claims than any other
single allegation made against physicians. A 1995 study by the Physician Insurers Association of
America indicates that problems with diagnosis of breast cancer are a major source of malpractice
loss for physicians who treat women.
According to the study, several factors contribute to delays in diagnosis: 1) failure of the physician
to be impressed by physical findings or patient complaints; 2) lack of timely follow-up; 3) negative or
equivocal mammogram report; and 4) misread mammogram.
Consider the following risk management recommendations:
• Do not exclude the possibility of breast cancer on the basis of a negative or equivocal mam-
mogram alone.
• Do not exclude the possibility of breast cancer because you are unimpressed by the physical
findings or patient complaints.
• Do not file a mammogram report in the patient’s chart unless it has been reviewed with the
exam findings and initialed by the physician.
• Follow up with patients when their condition warrants it. Systems should be in place to remind
physicians to follow up.
For further information, contact Lori Atkinson, MMIC risk management coordinator, MMIC West Des
Moines office, PO Box 65790, West Des Moines, 50265, 800/798-9870 or 515/223-1482
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Iowa Medicine Volume 85/ 9 September 1995 361
Iowa [Medicine
Newsmakers
CURRENT ISSUES
AT A GLANCE
A new partnership has
been formed between the
Cedar Rapids Physician-
Hospital Organization
(PHO) and Heritage Na-
tional Healthplan, a sub-
sidiary of John Deere
Health Plan. The PHO
and Heritage will intro-
duce a new managed
care health insurance
plan to eastern Iowa.
•
Dr. Kelly Ross, St. Ansgar,
1994 Iowa Family Doc-
tor of the Year, is one of
10 finalists for the na-
tional Family Doctor of
the Year award spon-
sored by the American
Academy of Family Prac-
tice.
Medical supervision of student athletes
Dear Editor:
I thought your readers might be interested in
and may benefit from a study regarding medical
supervision of Iowa high school student ath-
letes which was funded by the UI College of
Medicine and endorsed by the Iowa High School
Athletic Directors Association and the IMS
Committee on Sports
Medicine.
Questionnaires
were sent to 426 Iowa
schools; 403 were re-
turned for a response
rate of 94.5%. Results
showed medical su-
pervisors were in at-
tendance at 78% of sporting events with high
injury rates. Designated team physicians were
reported at 41% of schools, with family physi-
cians predominately at class 3A to A and family
physicians and orthopedic surgeons at class
4A. Approximately one-third of high schools
have athletic trainers. Health evaluation re-
ports for student athletes were reported at 85%
of schools and parental consent for treatment
at 87%. Thirty-three percent have written plans
for transportation of injured athletes and 64%
have a driver and vehicle designated for emer-
gency transportation. Training for CPR was
reported for 68% of coaches. The majority of
athletic directors indicated staff would benefit
from education on management of the down
athlete, rehabilitation programs, guidelines on
returning to competition and head injuries. —
Daniel Fick , MD, Iowa City
Awards, appontments, etc.
Dr. Bruce Gantz, Iowa City, has been ap-
pointed head of the Department of Oto-
laryngology at the UI College of Medicine. Dr.
Gantz has served in the position on an interim
basis for two years. Dr. Joseph Veverka, Prairie
City, was recently honored by Iowa Lutheran
Letter
to the
Editor
Hospital with an open house reception. Dr.
Veverka was cited for his “many contributions
to the medical staff and for the commitment
you have demonstrated and the achievements
you have made during your 30-year tenure at
Iowa Lutheran Hospital.” Dr. Wilbur Smith, UI
College of Medicine professor and interim head
of the Department of Radiology, has been elected
to a one-year term as president of the Associa-
tion of University Radiologists and a three-year
term as treasurer of the Society for Pediatric
Radiology. Dr. Edwin Stone, assistant profes-
sor in the UI College of Medicine, Department
of Ophthalmology, received a 1995 recognition
award for outstanding contributions to visual
research from Alcon Research Institute. Dr.
Ken Crawford has begun practice in the Paullina
Family Medicine Clinic, Sutherland Family
Medicine Clinic and Ohme Medical Center in
Primghar. Dr. Curtis Reynolds, Cedar Rapids,
has been named director of Primary Care Ser-
vices at Mercy Medical Center. Dr. Reynolds
previously served as director of the Cedar Rap-
ids Medical Education Program and the Family
Practice Residency Program. Dr. Gordon
Baustian has succeeded Dr. Reynolds as direc-
tor of both programs. Dr. Tony Myers has been
named assistant director of the Medical Educa-
tion Program. Dr. Andrew Patterson, Cedar
Rapids, is now physician director of Mercy Care
North. Dr. Patterson succeeds Dr. G.L. Schmitt.
Deceased members
Robert Barton, MD, 84, life member, der-
matology, St. Louis, Missouri, died May 2
John Downing, MD, 79, life member, pedi-
atrics, Marion, died May 6
W.D. Haufe, MD, 76, life member, internal
medicine, Bloomfield, died May 6
Russell Cox, MD. 75, radiology, Spirit Lake,
died April 26
Kathleen Smith, MD, 44, general surgery,
Des Moines, died June 4
Ralph Shepherd, MD, 73, anesthesiology,
Des Moines, died June 3 El
362 Iowa Medicine Volume 85/9 September 1 995
DIABETES
1995
a harvest of new ideas
■ Nov. 17, 1995
Downtown Des Moines
Botanical Center
■ Featuring Frank Vinicor, MD
I Director of Diabetes Translation, Centers
for Disease Control I President of the
American Diabetes Association
i Islet cell transplantation I Vegetarianism
■ Women’s issues I Oral therapies
■ Healthcare trends in the 90s
I For a brochure and registration
Or additional information
Call (515) 241-5074
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Iowa | Medicine
FEATURE ARTICLE
Managed
care
in Iowa
TRANSITION
On March 1, Meclco Behavioral Care began managing mental
health services for Iowa’s Title 19 population. The state says
Medco can improve access and save money, but many
providers and other patient advocates have grave concerns
about Iowa’s first major experience with managed care.
Christine McMahon
Ms. McMahon is director
of communications for
the Iowa Medical Society
and managing editor of
Iowa Medicine.
When Iowa psychiatrists gather these
days, there’s something interesting to talk
about.
On March 1, Medco Behavioral Care
(MBC), a New Jersey managed care company,
took over management of mental health care
for Iowa’s Medicaid population. The project is
groundbreaking on two fronts: it is Iowa’s
first major foray into managed care and Iowa
is only the second state in the nation to turn
all of its Medicaid mental health services over
to a managed care company.
Stating it mildly, Iowa psychiatrists are
concerned over some of Medco’s policies and
their possible effect on patients. However,
officials of the Department of Human
Services — which awarded the managed care
contract to Medco — say that steps are being
taken to address these concerns.
Brice Oakley, GEO of Medco of Iowa,
believes some of the problems experienced
by providers are the result of the transition
to managed care. He says Medco is trying to
do a better job at communicating with
providers and remains confident
that managed mental health care
can be successful in Iowa.
Survey results disturbing
Dr. Jerry Lewis, a Newton
psychiatrist and president-elect of
the Iowa Psychiatric Society (IPS),
says Medco’s relationship with
Iowa physicians began “with an
element of mistrust” when the company sent
out contracts containing a ‘hold harmless’
clause. (Hold harmless clauses shift liability
from the managed care company to
physicians. Lawyers consistently advise
physicians against signing contracts
containing such a clause. After negotiations,
the clause was removed. )
In a recent survey conducted by the IPS,
respondents expressed a litany of other
complaints about Medco policies and their
effect on patients.
Universal concerns include Medco’s denial
of hospitalizations for seriously-ill patients
who have no alternatives, inconsistency
among reviewers, no notification of changes
in procedures, slow payment of claims and
too much time spent on paperwork and in
dealing with denials.
Some respondents recounted specific
anecdotes involving children who were
denied hospitalization even though they
demonstrated “serious assaultive behavior”
or suicidal tendencies.
Several physicians complained
that they spend 45 to 60 minutes
on the phone every day or every
other day talking to reviewers
when they hospitalize a Medicaid
patient.
Some psychiatrists said they
may not sign a Medco contract;
others — including several young
physicians — said they are
“You need an
option for these
children before you
take them out of
the system.”
364 Iowa Medicine Volume 85 / 9 September 1995
FEATURE ARTICLE
reconsidering whether or not to continue
caring for Title 19 patients.
“I realize the state needed to save money,
but this is too much control,” comments Dr.
Lewis. “They’re taking money out of the
system and making it very difficult to get
care for patients.”
According to Dr. Lewis and others, one of
the major problems is Medco’s contention
that some kids now receiving services
through Medicaid actually belong in the
juvenile justice system.
“Rightly or wrongly, kids who have a
diagnosis of conduct disorder have been
handled in inpatient settings. Medco says
these kids aren’t psychiatrically ill. Whether
or not this is true, you need an option for
these children before you take them out of
the system. Now, most are just going back to
their families,” Dr. Lewis explains.
Medco meets with Ul staff
Physicians with the University of Iowa
Department of Psychiatry have held several
meetings with Medco representatives
regarding “a number of concerns we’re trying
to work out”, according to Bob Robinson,
MD, professor and department head.
Dr. Robinson says one area of concern is
authorization for hospital admissions for
patients who are not acutely dangerous but
have long-standing psycho-social problems.
UI physicians have also had difficulty dealing
with approval for continued stays in the
hospital.
“The kinds of problems we see here just
can’t be resolved in 24 hours,” he explains.
“We’re working with Medco trying to come
up with treatment plans so these patients are
approved ahead of time and we don’t have to
spend time on the telephone every day.”
Dr. Robinson says that the issue of placing
patients into lesser levels of care requires
more study.
“First, you have to study whether it’s
appropriate to care for some of these patients
at a lower level. Then you have to study
whether the lower level of care is even
available. Also, if someone isn’t responding
to local care, they may have to come here on
a scheduled basis. The problem is, Medco
abhors scheduled admissions.”
lie also points out that when patients
come from far away, options such as partial
hospitalization can only work if the patient
has somewhere to go at night. (Partial
hospitalization is part of a program to reduce
length of stays which began at the UI about a
year and a half ago.)
A follow-up meeting is planned at the UI,
at which time Medco is supposed to provide
new criteria for continued hospital stays,
possibly in a check-off format.
“Medco staff must appreciate the nature of
problems unique to a rural state such as
Iowa,” he concludes. “We are hopeful these
difficulties can be worked out."
Legal advocates are concerned, too
Tom Krause of Legal Services of Iowa says
implementation of the Medco contract was
“rushed” and that Medco’s criteria for
hospital admission are unacceptable.
“When the state receives federal Medicaid
dollars, it means they must provide necessary
care. The state contract with Medco gives
Medco the sole power to determine medical
necessity. This is not acceptable.”
There is also a problem with the appeals
process, says Krause.
continued
Be assertive, advises psychiatric office RN
Having someone like Brenda Downey, RN in your office may be a key factor
in your success with managed care.
“Sure, we get frustrated at times, but managed care is here to stay. This
population is the most problematic of mental patients — they are extremely
difficult to manage,” says Ms. Downey, the case manager in the office of Des
Moines psychiatrist Randall Kavalier, DO. “Our approach is to look for any
possible opportunity to accommodate our patients.”
Ms. Downey believes Medco is sincerely trying to correct problems. She also
believes that since managed care is new here, some Iowa physicians are
unaccustomed to the case management required for dealing effectively with
Medco and don’t know the right way to talk to the company’s reviewers.
“Don’t describe the situation — give your professional judgment based on
the facts of the situation. You’re trained and licensed to give a professional
opinion, give it without hesitation. Be sure you’re giving the correct
information to the reviewer and using the appropriate verbiage.”
Ms. Downey sometimes asks the reviewer to send a field representative to
Dr. Kavalier’s office and says these representatives have been “very helpful” in
cases where she and the telephone reviewer couldn’t agree on the need for
hospitalization. She is also not afraid to request that a physician reviewer
come to the phone and discuss a case with her.
“You’re the professional, you’re the patient advocate. Be confident and
assertive in the decisions you’ve made,” she advises.
‘The kinds of
problems we see
here just can't he
resolved in 24
hours ”
Iowa Medicine Volume 85 / 9 September 1995 365
Iowa | Medicine
FEATURE ARTICLE
continued
“We have one child
who has been
in 18 different
placements
in the past year.
These aren’t
fUSedco problems.”
“When you kick someone out of the
hospital, you effectively remove the appeals
process. So what if someone comes along
later and says the denial was wrong?”
Legal Services of Iowa, with the support of
the Youth Law Center, is monitoring Medco’s
operation in Iowa and is considering filing a
lawsuit on behalf of Medicaid recipients.
The Child Protection Council, a multi-
disciplinary group of child advocates, has sent
a letter to Governor Branstad asking that the
Medco contract he reconsidered “in light of
the multitude of bad experiences reported by
juvenile judges, county attorneys and health
care providers”. The letter expresses par-
ticular concern over Medco’s “unacceptable”
hospitalization policy for children who
express suicidal thoughts.
The Iowa Code says if children are a
danger to themselves or others, judges can
place them in a hospital, with Medicaid
picking up the tab.
However, Medco has reportedly denied
payment for some of these hospitalizations
and juvenile judges met recently with Medco
officials to discuss the problem. Bert Aunan,
chief juvenile court officer in the Fifth
District, said he is satisfied that Medco is
rethinking the issue.
“Some of these kids need hospitalization
because that’s the only way to get a true
assessment,” he explains. “Also, Medco has
said if there is a safety issue, the child should
stay in the higher level of care.”
Aunan said he and his colleagues are
concerned that Medco’s criteria are more
appropriate for adults than for children. They
are also apprehensive about the lack of
options for those denied hospitalization.
“We recognize Medco is going to have
shorter lengths of stay. Our task now is to
figure out how to provide and fund lower
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Providers are upset, as demonstrated by this typical comment from a recent Iowa Psychiatric Society survey.
levels of service.”
According to Aunan, facilities such as
group homes are not a feasible alternative to
hospitalization because they already operate
at near capacity. If the juvenile justice
system is going to be expected to step into
the gap, additional funding will be required,
he added.
“I’ll continue to advocate for kids,” he
stresses. “I believe Medco is taking a look at
the process and is willing to make changes.”
Problems inherent in the system
Des Moines psychiatrist Dr. Randall
Kavalier says it’s not surprising that
everyone in the system is struggling to make
the transition to managed care. A large part
of the problem could be that many
psychiatrists practice in areas where there is
no “safe back door” or lower level of care
available for children who stay only a short
time in the hospital or are denied for
hospitalization.
“I benefit front Mercy system because our
focus already is on shorter stays with a
continuum of care,” he explains. “I suppose
my style of practice is more consistent with
managed care.”
He confirms the “reluctance of the courts
to take young people and incarcerate them”
if they have not really committed a crime —
for example, a 10-year-old who brings a gun
to school.
“That child needs evaluation in an office
like mine. Some things just can’t be
determined by a simple checklist. Maybe he
brought the gun to school because he was
frightened.”
However, both Dr. Kavalier and his case
manager Brenda Downey, RN believe many
of the problems in the system existed long
before Medco came to town.
“My biggest concern is
how the whole system
works. The Department
of Human Services is
seriously overburdened,”
contends Ms. Downey.
“We have one child who’s
been in 18 different
placements in the past
year. Today, I applied for
emergency foster care for
ci a-
366 Iowa Medicine Volume 85 / 9 September 1995
F
a 4-year-old who tried to push his brother out
of a window and they told me it’s a six-week
wait. These aren’t Medco problems.”
Bill Dodds, managed care specialist with
the Department of Human Services Division
of Mental Health, says prior to Medco, Iowa’s
Medicaid program had “unfettered fee-for-
service” with no central management of
resources and little utilization management of
payment for mental health services.
“The goal of managed mental health care
was to reorganize the system to improve
access to services and contain costs,” he
explains. “Services needed to be available
more uniformly, especially in rural Iowa.”
He said another goal is to “empower”
Medicaid recipients to have more control
over their lives. The DHS and Medco have
planned six outreach meetings for people
with mental illness to give them information
on how to access the system and negotiate
directly with Medco.
Problems are being worked on
Dodds says there are legitimate concerns
with Medco policies but that he is “unaware
of any that aren’t being worked on”.
Dodds acknowledges there are problems
with the inter-relationship of funding and
services for Medicaid and the juvenile justice
system which existed before the Medco
contract, but says these problems are not
being ignored.
“Medco has been meeting with staff from
the DHS and juvenile services on
management of 25-50 difficult cases. This
gives us a chance to analyze what services
will be needed and manage the cases better.”
Some providers have reported unpaid
Medco claims which are four to five months
old; Dodds says Medco probably under-
estimated the level of claims they would have
to pay but is working to solve the problem.
Also, DHS is working toward making
available “safety net services” as alter-natives
to hospitalization. These services will include
24-hour crisis care, mobile crisis services,
respite services and improvements in the
“supported living” services which help spot
developing problems.
“This has been an ambitious project,”
Dodds comments. “It’s fair to say Medco is
doing a good job of what they have
experience doing.”
Resolving issues is ‘multi-year process’
Medco’s Oakley says successful imple-
mentation of the managed mental health
contract could be a multi-year process and
that there have been “significant difficulties”
in some areas.
“It’s very clear that we (Medco) needed
more experienced provider relations staff.
We learned that ‘early and often’ is the rule
for provider education and networking.”
He says Medco is now “fleshing out” its
criteria — criteria which were reviewed by
“national experts” but not shown to Iowa
providers before implementation.
The criteria were designed on a ‘medical
necessity model’ but are now being
expanded to take ‘service necessity’ into
consideration.
“We think the expanded criteria will be
more useful. This is Phase II — further
development of the lesser levels of care,”
Oakley explains. “We understand that the
mental health population sometimes has
needs that are non-medical.”
Oakley says statistics show Iowa having
the fifth to eighth highest in-patient rate for
Medicaid recipients.
“We need to utilize less intensive levels of
service through better communication
between physicians and reviewers,” he
explains. Medco’s goal, he continues, is to
move provider-reviewer encounters past the
issuance of denials to actual discussions of
all options available for the patient.
Oakley said staffing in the quality
management area has been shored up and
that Medco plans to send a newsletter to
providers under contract regarding changes
in policies and procedures. The company is
also close to implementation of a pilot
project for electronic claims.
Oakley says the state is going to a system
“where only certain providers have access to
the Medicaid population” but that there is
no firm deadline for this to take place. He
said he has no current information on how
many providers have signed Medco
contracts.
“We may have to contract for services in
areas of the state where there are gaps,” he
comments. DS1
A T U R E ARTICLE
“It's very dear that
w@ needed snore
experienced
provider relations
staff.”
Iowa Medicine Volume 85 / 9 September 1995 367
Medical Protective Policyowners
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Iowa | Medicine
SCIENCE AN D EDUCATION
The Journal
of the Iowa Medical Society
Metastasis of adenocarcinoma of breast to gluteus medius
# Subhash Sakai, MD; Darcy Leigh, DO
Breast carcinoma is the most common major
cancer in females in the U.S. It is the second
leading cause of deaths due to cancer in
women; it accounts for 19% of all cancer-relat-
ed deaths in women, second only to lung can-
cer.1 As of 1990, it was estimated that one in
every 10 American women would develop
breast cancer.2 The incidence has continued
to increase and was estimated to be one in
every 9 American women or 22.4 cases per
100,000 in 1992. 11 Detection of early disease
states and improved treatment modalities
have increased survival rates such that mor-
tality rates have remained relatively stable
even though the incidence has risen.1
Controversy remains as to whether breast
cancer is a systemic disease at the time of
diagnosis or if it is a stepwise progression of
metastasis.1 However, the number of axillary
lymph nodes involved continues to be the
largest prognostic factor. Metastatic cells are
shed into the venous circulation due to neo-
vascularized communications or via lymphat-
ic-venous communications. Ninety-five per-
cent of the deaths in patients with
uncontrolled breast cancer are those with dis-
tant metastasis. The most common sites of
dissemination include bone, lung, pleura, soft
tissues and liver, respectively. In 60% of
patients who develop metastasis, it occurs
during the first 24 months after mastectomy
and is the most common cause of death
between five and 10 years post-mastectomv1.
The following is an unusual case report of a
patient with metastatic adenocarcinoma of
the breast who presented with further dissem-
ination to the gluteus medius muscle.
Case presentation
A 64-year-old female presented to our clin-
ic for evaluation of sudden onset of severe
pain originating in her right buttock and radi-
ating to her right hip and lower extremity.
The patient’s past medical history was signifi-
cant for adenocarcinoma of the breast,
specifically infiltrating ductal carcinoma
involving a single lymph node. This was ini-
tially diagnosed and treated with lumpectomy
and radiation in 1990. Subsequent recur-
rence to the chest wall, axilla and pleura was
treated unsuccessfully with hormonal agents
(tamoxifen and megace), followed by a com-
bination of cytoxan, adriamvein and 5FU,
and a course of mitomycin and velban, then
most recently with taxol three weeks prior to
the onset of buttock pain.
Further past medical history includes
heavy alcohol abuse, chronic obstructive pul-
monary disease, polypectomy of an adenoma-
tous colonic polyp, left ovarian cyst with
oophorectomy, ectopic pregnancy with right
oophorectomy and salpingectomy and hem-
orrhoidectomy. Initial physical examination
revealed no erythema, edema or cutaneous
changes of the right buttock and hip, as well
as normal range of motion of the hip joint.
X-rays of the right hip and pelvis did not
reveal any evidence of osteoblastic or osteo-
clastic activity. Subsequently, an isotopic
bone scan was performed and also showed no
evidence of bony metastatic disease. Labora-
tory studies revealed WBC 10,300, RBC 3.74
X 106, HGB 10.6 g/dl, IICT 33.3%, MCV 89 fl,
MCI I 28.3 pg, RDW 16.4%, PLT 340,000 and
ESR 30 mm/hr.
During the next three days the patient’s
pain intensified and physical examination
revealed marked pitting edema of the right
buttock, hip and leg. These areas were also
extremely tender upon palpation. Range of
motion of the hip joint was within normal
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
September 1995.
Subhash Saiiai, MD
Dr. Sahai is a family
practice physician in
Webster City.
Darcy Leigh, DO
Dr. Leigh is a fam ily
practice resident at
Methodist Hospital,
University of Illinois.
Iowa Medicine Volume 85/9 September 1 995 369
Iowa [Medicine
SCIENCE AND EDUCATION
Metastasis of adenocarcinoma of breast to gluteus medius
continued
limits except for restriction in external rota-
tion. Computed tomotography of the pelvis
indicated diffuse enlargement and increased
vascularity of the gluteus medius muscle that
was related either to inflammatory or neo-
plastic origin. Fine needle aspiration of the
fluctuant buttock was obtained and sent for
both cytology and culture and sensitivity.
Ultrasound at this time did not reveal any
abscesses, so the patient was placed on anti-
inflammatory agents and dilaudid 2 mg every
four hours as needed for pain while awaiting
the aspiration results.
Two days later the patient’s pain was no
longer being controlled by oral medications
and she was admitted to the hospital for
intravenous patient controlled administration
of Nubain (nalbuphine hydrochloride).
Heparin 5,000 U SQ every 12 hours and
ampicillin 1.5 gm IVPB every six hours were
also begun. Laboratory studies revealed WBC
13,900, RBC 3.82 X 106, HGB 11.1 g/dl, HCT
34.0%, RDW 16.6%, PLT 351,000, ESR 33
mm/hr, sodium 145 meq/L, potassium 3.7
meq/L, BUN 7 mg/dl, creatinine 0.6 mg/dl,
chloride 105 meq/L, C02 31 meq/L, glucose
94 mg/dl, calcium 8.9 mg/dl, alkaline phos-
phatase 86 U/L, LDII 211 U/L, uric acid 2.3
mg/dl, total protein 5.8 g/dl, and albumin 3.6
g/dl. The pathology report of the hne needle
aspiration returned strongly suspicious for
adenocarcinoma and the culture was negative
for bacteria.
Treatment
Computed tomotography guided needle
aspiration of the gluteus medius muscle was
performed, which revealed a poorly undiffer-
entiated carcinoma with a histology consis-
tent with adenocarcinoma. A palliative radia-
tion course of 3,750 cGy in 15 treatments to
the right hemi-pelvis and gluteal muscle was
begun. The patient remained hospitalized for
pain control during the first 11 radiation
treatments, during which time she was
weaned from intravenous to oral medications
as her symptoms began to subside. The
patient was maintained at a relatively pain-
free level on oral medications (MS Gontin
[morphine sulfate control release] and
Naprosyn) and finished the course of radia-
tion at home.
Discussion
Infiltrating ductal carcinoma accounts for
the majority of breast cancers (75%). 6 They
commonly invade the axillary lymph nodes and
have the most ominous prognosis. They most
frequently metastasize to bone or intra-
parenchymal sites such as the lung, liver or
brain, whereas metastasis to the meninges,
serosal surfaces and other atypical sites is more j
common with lobular carcinoma.5,6 Generally,
the prognosis is directly proportional to the
number of lymph nodes involved. In our
patient’s case, only one axillary lymph node
was involved, but her disease progressed rapid-
ly to multiple sites. The most unusual site was
the ipsilateral gluteus medius muscle, which to
the best of our knowledge has not previously
been reported.
References
References noted in this article are avail-
able from the authors or the editors of Iowa
Medicine. US)
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370 Iowa Medicine Volume 85 / 9 September 1995
WHO ARE WE?
The Iowa Medical Group Management Association is a nonprofit organi-
zation whose membership is comprised of individuals engaged in the
administrative aspects of medical group practice. Our membership is
diverse, representing group practices operating under various organiza-
tional and financial structures. Current membership in IMGMA includes
over 500 people representing almost 3,500 physicians.
WHO CAM BELONG?
There are four classifications of members: active, affiliate, honorary and
life. Active membership is limited to persons who are serving in an
administrative capacity within a physician group practice, with the
exception of honorary, life and affiliated members. Affiliate members
are individuals who supply products or services to IMGMA members.
WHY JOIN liVIGSVIA?
1 IMGMA enhances your professional growth, development and
viability as a medical group manager.
2 IMGMA offers a variety of targeted educational opportunities.
3 IMGMA provides opportunities for members to share and dissemi-
nate information of mutual interest.
4 IMGMA maintains an active liaison with other key public and
private organizations that affect the management, funding and
delivery of quality physician care.
5 IMGMA dues are only $75 per year.
IOWA MEDICAL GROUP MANAGEMENT ASSOCIATION
lOOl Grand Avenue, West Des IVleines, 1A 5©2GS
Please send me an application for membership!
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fVMERCY
HOSPITAL
MEDICAL
CENTER
Mercy Hospital Medical Center
preienti
"MENTAL HEALTH CARE IN THE 90’S"
Wednesday, October 25, 1995
Guest Faculty
Donald Hay, M.D
Associate Professor of Psychiatry
St. Louis University School of Medicine
St. Louis, Missouri
Henry Nasrallah, M.D
Professor of Psychiatry/Neurology
Ohio State University College of Medicine
Columbus, Ohio
Thomas Murtha, M.B.A
Director, Circle of Care
Mercy Hospital Medical Center
Des Moines, Iowa
Donald Burrows, M.D
Director, Mercy Sleep Center
Mercy Hospital Medical Center
Des Moines, Iowa
Topics
"Office Management of Clinical Depression"
"New Managment Options in Bipolar
Disorders"
"The Systems Approach to Deveolping
Treatment Programs"
"Innovations in Sleep Therapy"
Jim Andrikopoulos, Ph.D "Neuropsychology: Cognitive and
Clinical Neuropsychologist Psychological Issues in Head Injury"
Private Practice
Des Moines, Iowa
Approved by Mercy Hospital Medical Center, an . Physician Fee $50.00
IMS-accredited CME organization for 4 hours of . Physician Assistant $25.00
Category I AMA Physician’s Recognition Award. . Nurses $25.00
. Nursing Personnel $25.00
Nursing CEUs: 0.5 (5 Contact Hours) . Pharmacists $25.00
Application has been made for additional accredita- . Paramedical $25.00
tions. See brochure. Resident/Student Complimentary
This seminar will be held at the Mercy Education Center, Fifth Street and University Avenue,
Des Moines, Iowa. Parking adjacent to the Education Center.
Please contact: Department of Medical Education • Mercy Hospital Medical Center
400 University • Des Moines, Iowa 50314-3190 • 515-247-3042
Iowa] Medicine
THE EDITOR COMMENTS
Drive-thru delivery
A cartoon in the Des Moines Register
(July 18, 1995) depicts a hospital with
a large sign over the door “General
Insurance Go. and Hospital”. The word “hos-
pital” is in smaller sized letters. The cartoon
further has a sign directing patients to a “dri-
ve-thru” delivery area. A pompous appearing
man complete with brief ease is emerging
saying “Since we make the decisions we felt
we should have top billing.” This cartoon
refers to a recent decision by insurance com-
panies that birthing should entail only a 24-
hour confinement period.
Over the past decades there has been an
insidious trend toward decreasing the time
allocated for maternity stays in hospitals. A
number of years ago, it was 10 days with the
first five days requiring the mother
to remain at bed rest; then the
stay was decreased to five days
with the mother urged to be more
active. Now, it’s “in, up and out.”
The increasing frequency of
out-patient surgical procedures
has certainly been conducive to
shorter maternity stays. With
births, however, we have two patients. The
new mother has a helpless infant to care for.
Gan the father obtain sick leave? Gan a
grandmother leave her home far away to help
her daughter? Are there neighbors who can
help as in years past ... or are all of them
employed full-time outside their homes?
What’s a mother to do? Some would say this
is a social problem and has nothing to do
with health care delivery. How crass!
So far, little has been said about the new-
born infant. Have far-sighted pediatricians
been consulted about the short hospital
stays? If jaundice ensues, imagine how diffi-
cult it will be for the mother to go to the
physicians’ office for evaluation of the infant;
and most likely elsewhere if laboratory deter-
minations are indicated. If the family is
involved with an HMO, the “Mickey Mouse”
routine of arranging consultations might be a
factor.
This all becomes very complicated. Our
medical world has changed very drastically.
Health care delivery has become the domain
of persons other than those involved in the
time-honored physician-patient relationship.
The battle cry is to cut medical
costs but it appears that eventual-
ly there are no cuts. Profits will go
to the stockholders and the
administrators of health manage-
ment rather than to the providers
and to reduce health care costs.
We must educate our
patients of all the hazards facing
the delivery of health care. We physicians
must be cognizant of the traps that are being
laid before us. Our patients must be consid-
ered first and foremost. After all, in the long
run, it’s their health and their money. [Qj
We physicians
must be
cognizant of
the traps that
are being laid
before us.
Marion .Alberts, MD
Iowa Medicine Volume 85 / 9 September 1995 373
Happy
Rath !!
40 Years9
Service
To Iowa
Physicians! !
And, Going
Strong!!
In 1955 Ruth Clare’s name was brand new
to Iowa physicians.
That’s changed dramatically over 40 years.
Now, in 1995, Ruth’s name is well known to
Iowa Medical Society members and their
staffs.
We’re proud to salute Ruth on the fortieth
anniversary of her employment, first with
The Prouty Company, and now with its suc-
cessor, Bernie Lowe & Associates, Inc.
To many Iowa doctors and clinic managers,
Ruth is a cordial voice on the telephone or
a signature at the bottom of an informative
letter. On other occasions, she’s a pleasant
face across the table in your office or ours —
explaining how a particular IMS-sponsored
insurance program works.
Ruth continues to represent BLA ably. She’s
real life testimony to our commitment of
service to Iowa physicians.
Please join us in congratulating Ruth on her
long and excellent performance. She and all
of us at Bernie Lowe & Associates are proud
of our long association with the Iowa
Medical Society.
Call us when we can help with your per-
sonal insurance needs — or those of your
practice.
BERNIE LOWE & A55BEIATE5. INC.
Insurance Administrators to Professional Associations 6 i
Universities and Colleges
515-000-OB11 1-BOO-940-4710 FAX 515-000-0915
07 □□ Westown Parkway. Suite 410
West Des Moines. Iowa 50055-1411
Iowa | Medicine
THE ART OF MED I C I N E
Remembering
Growing older often provides occasions
to recall and reflect, as long as we
haven’t yet lost those abilities. So it
was with me recently when 35 of my medical
school classmates gathered for a reunion.
Those of us who chose to attend and were
1 physically and fiscally able to do so looked
i pretty good, I thought.
I was impressed with how many of the
class of 1955 had already entered retirement,
and I don’t mean just “slowing down’’. I’ve a
hunch most of us at our graduation would
have thought it either outrageous or ridicu-
lous if someone had predicted the reality that
has occurred. I won’t pause now to muster
the diverse factors that probably led to the
individual decisions; it might make an inter-
esting exercise for later, though.
Fourteen of the 107 of us are
known to have died. That's proba-
bly a pretty good record, actuarial-
ly speaking, but reading the list of
the dead certainly dampens the
general atmosphere of partying
and celebration.
The University of Iowa Alumni
Association provided a display of major news
events of 1955. They didn’t say whether the
point was to amuse us, or force us to face our
mortality. Boy, was that list a shock: U.S.
Begins Aid to Indochina; Nikita Kruschev
Becomes Party Secretary; Supreme Court
Orders End to School Segregation; Military
Ousts Juan Peron; Ike Suffers Heart Attack;
George Meany to Lead Merged AFL and CIO;
Dow Jones Average Ranged Between 391 and
488; James Dean Scores Big in “Rebel With-
out a Cause”; Lawrence Welk Show and Cap-
tain Kangaroo Have TV Premieres; top box-
office stars include James Stewart, Grace
Kelly, John Wayne, Humphrey Bogart, June
Allvson and Clark Gable; hit songs were “The
Ballad of Davy Crockett” and “Love is a
Many-Splendored Thing”; “Cat on a Hot Tin
Roof” wins Pulitzer Prize; Marian Anderson
breaks color barrier at the Met; Disneyland
opens in Anaheim; Richard Nixon proclaims
“Sincerity is the quality that comes through
on television.” New terms appeared: auto-
mated, junk mail, blast off, third world.
On the medical scene, infant mortality in
the U.S. was then 26.0/1000 (now about 8.0)
and there were 214,000 U.S.
physicians (now more than
600,000). “The Pill” came into
use, prednisone was introduced,
chloramphenicol was found to
cause some hematological trouble
and Thorazine and Reserpine
were found effective for severe
mental illness.
Not everything that seemed to be progress
then has maintained its luster — all known sil-
ver linings have their dark clouds. If I attend
my 50th anniversary reunion, I’m sure I’ll be
amazed, impressed and both delighted and
saddened at what will have transpired
between now and then. I guess I’d like to
hang around and find out. EH
Not everything
that seemed
to be progress
then has
maintained its
luster.
Rickard Caplax, AID
Iowa Medicine Volume 85 / 9 September 1995 375
Iowa [Medicine
Classified Advertising
General Surgeon BE/BC
The Department of Surgery at the Mayo
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surgeons to join a Mayo Regional Facility in
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\ ACUTE CARE, INC.
' PO Box 515, Ankeny, LA 50021
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Mankato Clinic, Ltd. — A progressive group
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or write 1230 East Main Street, P.O. Box 8674,
Mankato, Minnesota 56002-8674.
Assistant Residency Director, Department of
Family Practice, LTniversity of Iowa College of
Medicine — The Department of Family Practice
at the University of Iowa College of Medicine is
seeking an ABFP-certified physician to join the
faculty as an Assistant Residency Director.
Responsibilities include curricular design,
procedural skills training and resident
recruitment. The successful candidate will
have practice experience and a minimum of
one year teaching experience at the residency
level and have competency in obstetrics. The
department has a well-established 24-resident
program that is university-administered,
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built and expansion beyond the present one
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part of the full academic department,
responsibilities include teaching, research and
patient care. Academic appointment can be in
either the traditional tenure track or a new
clinical track. Scholarly activity is expected
and supported. Appointment and salary
commensurate with qualifications and
experience. The University of Iowa is an
Equal Opportunity/ Affirmative Action
Employer. Women and minorities are strongly
encouraged to apply. Submit a letter of
interest and CV to George R. Bergus, MD,
Residency Director, Department of Family
Practice, 2015 Steindler Building, Iowa City,
Iowa 52242; 319/335-8456.
Des Moines — IM, FP, PD needed to join
growing elite practice! Above average salaries,
good call coverage, excellent benefits. Call
Mary Latter at 800/520-2028! Job #M141MJ.
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Marshalltown Medical
& Surgical Center
Seeking quality primary care
trained or emergency medicine
physician to practice at MMSC.
• Stellar EM practice
• Full-time, regular part-time and
moonlighting opportunities
• 14K annual volume
• 12-hour shifts, 24-hours/7day
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• Excellent benefit/bonus packages
• Paid St. Paul malpractice
Send CV or contact
Melissa J, Milliken, CMSC
1 ACUTE CARE, INC.
• PO Box 515, Ankeny, LA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Springfield, Missouri — Bass Pro Shop and 40
miles to Branson. BE/BC FPs. OB optional,
salaried position and production bonus, call
1:7, teaching hospital, university community.
Contact Vivian M. Luce, Cejka & Co., 1/800-
765-3055 or fax CV for immediate attention to
314/726-3009 (IMs welcome).
Escape from the ordinary ! — General surgeon
needed to work in our thriving rural family
practice. Candidate should have skills in C-
section, gyne and laparoscopic surgery. Eight
weeks vacation/CME. Consultants available.
Only group in county with 3 referral centers one
hour away. Uniquely situated on 1-94 half way
between Madison and Twin Cities. Small town
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Cohesive group of caring physicians! Contact oi
send CV to Gary K. Petersen, Krohn Clinic, Ltd.
610 W. Adams St., Black River Falls, Wisconsir
54615; 715/284-4311.
376 Iowa Medicine Volume 85/ 9 September 1995
CLASSIFIED ADVERTISING
Floyd County
Memorial Hospital
Seeking quality primary care
trained or emergency medicine
physician to practice at FCMC.
1 Regular part-time or moonlighting
opportunities
’ Weeknights, 12-hour shifts
> Low to moderate volume
1 Highly competitivecompensation
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Melissa J. Milliken, CMSC
ACUTE CARE, INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Knoxville VA Medical Center — is currently
seeking applications for the position of Chief,
Medical Service. Candidates must be board
certified in internal medicine and have
experience in the VA system. Applicants must
have a demonstrated commitment to patient
care as well as supervisory and leadership
experience and capabilities. The focus on a
primary care model will provide a unique
opportunity for the selectee to develop and
implement a marketing strategy to broaden
the customer base, while providing the highest
quality of health care to the veterans seeking
treatment at KVAMC. As the Medical Center
has converted to electronic medical records,
computer skills are desirable. (Training is also
available on station.) Interested applicants
who meet these qualifications and are
interested in the challenges and rewards this
position could provide should contact David K.
Kentsmith, M.D., Chief of Staff at 515/828-
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Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
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established family medicine practice in central
Iowa. Practitioner has support of over 80
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in same multispecialty group. Full privileges
for a residency-trained family physician at
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MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
STORM LAKE. IOWA
Rural lakeside community provides unique
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Pritchard, Administrator, Buena Vista
Clinic, Box 742, Storm Lake, Iowa 50588;
collect 712/732-5012; fax 712/732-2538.
Family Medicine — Loving your job is no longer
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S3
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23
end shifts
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W
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• Excellent benefit/bonus packages
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■fa 000 00 30
Bail BODODC30
1 Melissa J. Milliken, CMSC
'y'vdoaooaaoE
d .iflDQBOCCa
8!Sr?S8
A ACUTE CARE, INC.
M?. jGQOocaai.
'SuOOOGOC
1 . CIJ3 oonco
' PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Time For a Move?
BC/BE FP, IM, OB/GYN, PEDS
Our promise — We’ll save you valuable time by
calling every hospital, group and ad in your
desired market. You’ll know every job within
7 days. We track ever}' community in the
country, including 2000+ rural locations. Cedar
Rapids, Des Moines, Quad Cities, Kansas City,
Boston, Chicago, Indianapolis, many more.
New openings daily — call now for details!
The Curare Group. Inc.
M-F 9am-8pm, Sat 1-5 pm EST.
800/880-2028, Fax 812/331-0659
.lob #C133MJ
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for $2.00
per line with a 830 minimum per insertion
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for 825 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85/ 9 September 1995 3 77
Iowa [Medicine
CLASSIFIED ADVERTISING
Family Physician — Family Medical Center is
actively recruiting a BE/BC family physician to
join 8 other family physicians and one general
surgeon. Practice opportunity provides 1:9 call
schedule, with full-time hospital ER coverage.
Contract provides for attractive salary and excel-
lent benefits. Send CV to Linda Cohrt, Office
Manager, 1225 C. Avenue East, Oskaloosa, Iowa
52577 or fax 515/672-2258.
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
of Des Moines. We have a beautiful new
facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
Director, Obstetrics and Gynecology —
Broadlawns Medical Center, a 200+ bed
county/community teaching hospital serving
metropolitan Des Moines and Polk County, is
seeking a well-rounded physician to direct the
ob/gyn department. Activities will include
supervising patient care teaching of family
practice residents, a rotating ob/gyn resident
and medical students in OB (500 births per
year and growing). Department includes
medical office clinical facilities, a Family
Birthing Center with LDRP room accommoda-
tions; a Family Planning Program and mid-wife
positions. Qualifications include an MD or DO
degree, board certification or active candidacy
of the American Board of Obstetrics and
Gynecology, extensive practice experience and
the ability to direct staff and programs to
support the service and education goals of the
facility. Clinical teaching experience is
desirable. Post offer/pre-emplovment physical
and drug screen required. This is a University
of Iowa clinical appointment. Take the
challenge and join our team! If interested
contact D.J. Walter, MD, 1801 Hickman Road,
Des Moines, Iowa 50314; 515/282-2203.
Minorities and women encouraged to apply.
Broadlawns is an Equal Opportunity/Affirma-
tive Action Employer.
Family Practitioner • Internist
I30TH
Want the best of
worlds?
Live and work in a rural community-yet have easy
access to the educational, cultural, shopping, and en-
tertainment opportunities of the big city. Enjoy all the
benefits that go with small-town living-good neigh-
bors, safe schools, affordable housing, abundant rec-
reational choices-and go to the city when you want!
St. Croix Falls, Wisconsin is located just over the
scenic St. Croix River from Taylors Falls, Minnesota and
within 45 minutes of the metropolitan Twin Cities. With
25,000 households within the clinic service area, River
Valley Medical Center is the region’s largest and most
diversified practice group-13 family practitioners, 2
internists, 2 general surgeons, 2 orthopedic surgeons
and a physician assistant. Clinic is attached to a 50-
bed acute care hospital with a wide range of services.
Guaranteed first -year salary with second-year part-
nership and excellent fringes.
Send detailed CV to:
Cathy Kortas
River Valley Medical Center
208 S. Adams St.
St. Croix Falls, Wl 54024
Orthopaedic Surgeon, Clinton, Iowa
For general orthopaedics. . . Join our 32-physi-
cian multispecialty group partnership with a
newly expanded, modern 70,000 square feet
office. Group established and thriving 29 years.
Strong referral base and excellent industrial
base and support. Compensation competitive.
Positions also in Logansport, Indiana and
Effingham, Illinois.
Dermatologists Wanted
6 immediate positions. Miami Beach and North
Florida, Minnesota, Georgia, California and Texas.
BE/BC required. Salary to $200k and negotiable.
Ob/gyn & Plastic Surgeon Wanted
Open your own practice in our Miami Beach,
Florida very successful multispecialty group. No
fees, just split overhead expenses. BE/BC and
Florida license required.
Fax or send CV or call Avionne Allen
Physician's Placement Management Group
1000 Blythwood Place, Suite C-199
Davenport, IA 52804
800/251-6937 or fax 800/289-9754
Floyd Valley Hospital
Seeking quality primary care
trained or emergency medicine
physician to practice at FVH.
• 4300 average volume ER
• Medical director and staff posi-
tions
• Full-time, regular part-time and
moonlighting opportunities
• Weeknight, 12-hour shifts and
weekends
• Highly competitive salary
• Paid St. Paul malpractice
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE , INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
378 Iowa Medicine Volume 85/ 9 September 1995
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-562-2218
Des Moines: 515-245-4688
Iowa] Medicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrey, MI), PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MI)
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljko K. Zivkovich, MI)
Robert A. Colman, MI)
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Robert J. Barry, MI)
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Bligard, MD, FAAD
James I). Bunker, MD, FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milner-Brage, MD
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gervich, MI)
Daniel J. Schroedcr, MD
Ravi K. Vemuri, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/I nfertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Brandt, MD, ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MD
Laurence S. brain. MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgese, MI)
Loren J. Mouw, MD
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
llosung Chung, MI)
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
380 Iowa Medicine Volume 85/9 September 1 995
PROFESSIONAL LISTING
Neurosurgical Services LLP
•Robert Havne, MD
Thomas A. Carlstrom, Ml)
David .1. Boarini, Ml)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MI)
S. Randy Winston, MD
Douglas R. Koontz, Ml)
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad I). Abcrnathey, MI)
1953 1st Avenue SE
Cedar Rapids 52402
1319/363-4622
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, Ml)
John M. Graether, MD
Gilbert W. Harris, MD
James A. Davison, MD
Norman F. Woodlief, Ml)
Erie W. Bligard, MD
David 1). Saggau, MD
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
5000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
304 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
■iartori Professional Building
516 South Division Street
Hedar Falls 50613
319/277-0103
314 - 13th Street Southeast
ledar Rapids 52403
119/362-8032
Ophthalmic Associates, PC
Robert D. Whinery, MD
Stephen II. Wolken, MD
Robert B. Goffstein, MD
Lyse S. Stmad, Ml)
John F. Stamler, MD, PhD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MI)
Randall S. Brcnton, MI)
James L. Diimmett, MD
Mick E. Vanden Bosch, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Otolaryngology
Iowa ENT, PC
Thomas A. Ericson, MD
Marshall C. Greiman, MI)
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlab, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Ilill, MD
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Iowa Orthopaedic Center, PC
Marvin H. Dubansky, MD
Marshall Flapan, MI)
Sinesio Misol, MI)
Joshua D. Kimelman, DO
Timothy G. Kenney, MD
Lynn M. Lindaman, MI)
Jeffrey M. Farber, MD
Kyle S. Galles, MD
Scott A. Meyer, MD
Cassini M. Igram, MD
Rodney E. Johnson, MD
Martin S. Rosenfcld, DO
Donna J. Bahls, MD
Jill R. Mcilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Ju
Iowa Medicine Volume 85/9 September 1 995 381
Iowa [Medicine
PROFESSIONAL LISTINl
Iowa Head and Neck Associates, PC
Robert T. Brown, MI)
Eugene Peterson, MD
Richard II. Merrick, MI)
Peter V. Bocscn, MD
Robert R. Updcgraff, MD
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Ilead & Neck
Surgery, PC
Thomas Benda, Sr., MD
James W. White, MD
Craig C. Herther, MD
Thomas J. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MI)
Guy E. McFarland, MD
Thomas F. Viner, MD
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial , Plastic, Head & Neck
Surgery
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear , Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Perinatology
lies Moines Perinatal Center, PC
Neil T. Mandsagcr, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MD
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matysik, DO
Donald R. Shumate, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Surgery
Wendell Downing, MI)
1212 Pleasant Street. Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice D. Schncll, MD
Farccduddin Ahmed, MI)
Arthur B. Scarlc, MD
Bogdan E. Krvsztofiak, MI)
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Rehabilitation Medicine Associates
William I). dcGravellcs, Jr., MD
Charles F. Dcnhart, MI)
Marvin M. Hurd, Ml)
William C. Koenig, Jr., MD
Karen Kicnkcr, MI)
Todd C. Troll, MD
Lori A. Sapp, MI)
Younkcr Rehabilitation Center
Iow a Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Advertising Index
Bemie Low e & Associates
Blue Cross Blue Shield
Central Systems. Inc
Clarkson College
Dale Clark Prosthetics
Franciscan Skenip Healthcare
Iowa Methodist Medical Center....
IMGMA
IMPAC
IMS Services
Josephs
Medical Protective
Mercy Hospital 357.
MMIC
Monroe Clinic
River Valley Medical Center
U.S. Air Force
U.S. Armv
374
379
361
353
383
359
363
371
34f
357
35(
368
37;
38-
36.
37, '|
36
35'
382 Iowa Medicine Volume 85/ 9 September 1995
Iowa [Medicine
THE PRESIDENT COMMENTS
Why I belong
Iowa has a proud tradition of participation
in organized medicine. Currently better
than 4,100 physicians or 82% of eligible
physicians belong to the Iowa Medical Soci-
ety; approximately 75% of these belong to the
\MA. I hope we will continue this tradition
in the future.
There are many benefits to belonging to
he Iowa Medical Society. Some are rather
intangible, such as the results of efforts of
>hysician committees and staff, representa-
ion in the Iowa Legislature, the Governor’s
iff ice, state agencies and third party payers,
lontributions to IMPAC — our bipartisan
'olitical action committee — help support the
MS efforts on vital issues such as reduced
itatute of limitations for minors.
There are also benefits for the
udividual and group practices
inch as the professional liability
lsurance, health, life, disability
find worker’s compensation insur-
ace. The IMS provides adminis-
rative assistance to specialty soci-
ties, financial and retirement
$ lanning services, long distance «««■
lephone and overnight delivery service pro-
rams, practice management programs and
35oJbbt collection.
3681 Each year the IMS strategic plan is
viewed and updated to focus on physician
3^eeds. One of the important current issues is
sisting physicians practicing in a managed
lire environment. The IMS is also helping
nysicians with CHMIS and data technology
Each year the
IMS strategic
plan is reviewed
and updated
to focus on
physician needs.
management. Most importantly, the IMS is
an advocate for the physician and the
patient.
One complaint sometimes used as a rea-
son not to join is that the IMS “doesn’t repre-
sent my ideas or interests.” IMS policy is set
by the House of Delegates and those who
wish to become a delegate can usually do so
without a great deal of difficulty. This gives
them the opportunity to express their views
and enter the debate that shapes IMS posi-
tions on various issues. This does not mean
that everyone is satisfied by the outcome of
the vote but everyone has an opportunity for
a fair hearing of opinion.
If you do not think your ideas or interests
are being represented become a delegate.
Another option is to serve on one
of the IMS committees.
Organization is the key to effec-
tively advocating for patients and
for many issues that face us.
We are the “keepers” of medi-
cine today as were those before us
and as will be those after us. We
Jo it best through organizations
like the IMS. Join today! O
Joseph Hall, MD
Iowa Medicine Volume 85 / 10 October 1995 391
Iowa | Medicine
IMS Update
AT A GLANCE
The fund-raising drive
for the Iowa Medical
Society Education Fund
is underway. To date,
seven pledges totaling
814,600 have been
received, plus 87,600
pledged by other indi-
viduals. All IMS mem-
bers are urged to con-
sider contributing to the
IMS Education Fund,
the largest source of
non-governmental
loans for Iowa medical
students.
•
According to a recent
survey of 1,017 Iowa
physicians, the biggest
concerns in health care
are quality vs. cost and
government/insurance
company involvement
in health care. While
75% of respondents
agreed physicians have
more bargaming power
in tandem with hospi-
tals, only 1 6% said these
physicians provide high-
er quality care than
physician groups not in
a partnership with a
hospital.
Patient Grievances Increase
The number of patient grievances re-
ceived at IMS headquarters has been on the
increase. Most of these complaints are the
results of poor communication.
Physicians are encouraged to take time to
explain diagnoses and treatments to patients
and their families. A little more time and
demonstrated compassion can go a long way
toward creating good will and possibly pre-
venting liability claims. Remember, your
office staff members play an important role
in a patient’s overall perception of the quali-
ty of care received.
Directory mailed; dues statements coming
The 1995-96 IMS Membership Directory is
scheduled to be mailed soon to all IMS mem-
bers. The directory contains a listing of all
IMS members and other information regard-
ing individual physician practices, county
medical societies and specialty societies. On
the back of the directory is a list by subject of
the appropriate IMS staff member to call for
information.
IMS 1996 dues statements are also sched-
uled to be mailed soon, with a message from
Joseph Hall, MD, IMS president. Prompt pay-
ment of your dues will be appreciated.
Infant mortality continues to decline here
Iowa’s infant mortality rate is continuing
its decline, according to a report on 1994
Iowa vital statistics just released by the
Department of Public Health. Fetal deaths
(stillborns) dropped dramatically over the
past year and the number of heart disease
deaths dropped to expected levels after a
one-year jump.
However, officials are taking a closer look
at two categories of deaths — motor vehicle
crashes and accidental deaths. The death
rate in both these categories climbed dramat-
ically during 1994. The deaths caused by
motor vehicles went from 16.5 per 100,000
Iowans in 1993 to 18.3. The deaths due to
accidents went from 19.9 to 21.3.
For a free copy of 1994 Vital Statistics in
Brief, send a stamped, self-addressed enve-
lope to: Center for Health Statistics, IDPH,
Lucas State Office Building, Des Moines, IA,
50319-0075.
“Bridging Science and Program”
The national violence prevention confer-
ence to be held October 22-25 at the Des
Moines Convention Center has been
approved by the LTniversitv of Iowa for 16
Focus on IMS Alliance
With the coming of the fall season and cooler
weather comes the IMS Alliance Fall Board meet-
ing in Amana October 11-12 and our national pro-
ject SAVE Today (Stop America’s Violence
Everywhere). SAVE project events will be held
annually on the second Wednesday of October,
beginning October 11, 1995. Every medical
Alliance is urged to do something on that day to
focus attention on this devastating social problem
which robs so many Americans of quality living.
At the Alliance’s Fall Board meeting we are
focusing on membership. Our speaker is national-
ly known columnist Marilyn Motes Kennedy. For
11 years, Kennedy was the “Job Strategies” edi-
tor for Glamour magazine. She is a frequent con-
tributor to many national publications including
Working Women, Boardroom Reports and Modern
Maturity. She has appeared on “20/20” and
“Good Morning America.” Kennedy is past presi-
dent of the Chicago Headline Club and the
Chicago chapter of Women in Communications.
She will conduct a mini-workshop on how to make
the Alliance vital to our members. For more infor-
mation, call Sandy Nichols at IMS headquarters,
515/223-1401 or 800/747-3070.
Contributed by Linda Miller, president. IMSA
392 Iowa Medicine Volume 85 / 10 October 1995
CURRENT ISSUES
credit hours of continuing medical education.
The conference, entitled “Bridging Science
and Program” is cosponsored by the Centers
for Disease Control and the University of
Iowa Injury Prevention and Research Center.
Participants are expected from across the
country.
For registration information, call the
University of Iowa Conference Center at
319/335-3231.
Specialty Society Update
The Iowa Psychiatric Society has completed a
survey of members’ experience with the Iowa
Mental Health Access Plan, currently contracted
to Medco Behavioral Care Corporation of Iowa. A
litany of problems with the program were outlined
in the survey responses. The IPS Executive
Committee is making plans to distribute the sur-
vey results to public officials.
The Iowa Psychiatric Society Annual Meeting is
October 27-28 in Iowa City.
The Iowa Medical Group Management Association
Annual Meeting was September 13-16 at Lake
Okoboji. The theme of the meeting was “team
building” and featured representatives of the
Association of Iowa Hospitals and Health Systems
talking about partnerships between doctors and
hospitals and the new integrated delivery net-
1 works being developed around Iowa.
The American Medical Directors Association —
Iowa Chapter held its annual meeting in Iowa City
September 29-30.
The Iowa Society of Rehabilitative Medicine fall
membership meeting was held Friday, October 6
at IMS headquarters. Topics addressed included-
state and federal legislation and emerging orga-
nizations in the health care delivery system.
The Iowa Oncology Society will hold its annual fall
membership meeting Friday, October 27 at the
McFarland Clinic in Ames. Joseph Bailes, MD of
the American Society of Clinical Oncology will
speak on reimbursement and other issues.
The Iowa Association of County Medical
Examiners Board of Directors met at IMS head-
quarters on Friday, September 29 to make final
preparations for the annual meeting. The annual
meeting will be Friday, November 3 at the
Sheraton Inn in Cedar Rapids (note new location).
For more information about any of the above
meetings, call IMS Services at 515/223-2816 or
800/728-5398.
Attention: Internet surfers
The American Medical Association now
has a “home page” on Internet. The AMA
page — which includes JAMA and other AMA
publications — has been on the Internet
since August 1. The AMA’s Internet address
is: http://www.ama-assn.org. Eul
Association now
has a “home page”
on the Internet.
The American
Medical
Occupational Medicine
Des Moines, Iowa
(Career Practice Opportunity)
OccuSystems, Inc. is the largest national occupational health care
practice management company in the U.S. today. We are currently
seeking a primary care physician for our occupational health center
in Des Moines, Iowa.
Occupational medicine experience is desirable but not required . We
offer regular work hours with a limited rotating call. In addition, we
guarantee an excellent starting salary along with a year-end bonus
program. Plus progressive future growth and a comprehensive corpo-
rate fringe benefit program . The chosen candidate will assist in the
development of the Des Moines, Iowa market.
If you are interested or would like additional information on this or
other opportunities, call Jeff Moffett, C.M.S.R. or Matt Mearat 1-800-
345-9958 or send your CV to:
Recruiting Dept.
OccuSystems, Inc.
3010 LBJ Freeway, Suite 400
Dallas, Texas 75234
OccuSystems, Inc.
Innovative solutions
for occupational healthcare
OccuSystems , Inc. is an equal opportunity employer.
Iowa Medicine Volume 85 / 10 October 1995 3 93
Iowa | Medicine
Futures
AT A GLANCE
Blue Cross and Blue
Shield has unveiled
HMO-USA, a nationwide
Medicare managed care
network that unites its
member plans to extend
Medicare managed care
coverage across state
lines. Fifteen indepen-
dent plans have agreed
to participate in a net-
work that will cover 45
states. Iowa is not
included in these 15
plans but probably will
participate in the
future. Minnesota and
Missouri are part of the
network.
•
Another PHO is under
investigation by the
Justice Department for
possible antitrust vio-
lations. Justice is in-
vestigating to deter-
mine if the Baton Rouge,
Louisiana Women’s
PHO, formed by a hos-
pital and 144 ob/gyns
on the medical staff, is
monopolizing the area
market and whether
fee-setting constitutes
price-fixing.
Managed care prediction for Iowa
Managed care will dominate in Iowa within
five years, according to a speaker at the 1995
Iowa Family Practice Opportunities Fair.
Ted Schwab, a partner in the management
consulting firm of Schwab, Bennett and
Associates, said managed care markets do
not always follow an orderly development.
They sometimes skip from first generation to
third generation products (integrated deliv-
ery systems) quickly.
The cost of delivering medical care is going
down, while premiums paid for care continue
to rise, Schwab told his audience. This means
someone is reaping the profits. Schwab dis-
cussed several models for who will benefit —
in California, proprietary companies reaped
the profits, in San Diego the hospitals got the
profits and in Indianapolis the physician
community led development of managed care
and thus derived the profits.
He also discussed the potential growth of
managed service organizations (MSOs) which
will be the “integrators” in third generation
managed care products. These MSOs will
serve as experts on computer systems, data
analysis, physician compensation, outcomes,
operations management, etc.
Schwab cautioned that these integrators
are not “retooled” hospital administrators or
clinic managers because the skills needed are
outside their experience.
Managed substance abuse treatment
The Iowa Department of Human Services
(DIIS) and the Iowa Department of Public
Health are jointly implementing a managed
substance abuse treatment program to serve
both Medicaid clients and non-Medicaid
clients with income at or below 400% pover-
ty level.
The Iowa Managed Substance Abuse Care
Plan (IMSAGP) began serving clients across
Iowa on September 1 .
The National Council on Alcoholism (NCA)
has contracted with the Departments to
implement the IMSACP with their subcon-
tractor Medco Behavioral Care (MBC) of Iowa.
Clients served through the IMSACP will
have access to substance abuse treatment
through substance abuse network providers
and, for Medicaid clients, through current
hospital based substance abuse programs
under contract with IMSACP
Private practice physicians will be paid for
office visits (billed under E & M codes) dur-
ing which a physician determines that refer-
ral for substance abuse treatment is appro-
priate. DIIS will notify physicians directly
about this policy.
The provider toll free number is 800/836- |
8619. This number may be used for referral
to a substance abuse treatment program
through Medco or to obtain pre-authoriza-
tion for treatment for Medicaid clients. For ,
referral, physicians may also give the client
number — 800/252-5881 — to patients.
Non-Medicaid clients may be referred
directly to an IMSACP substance abuse
provider network.
For questions regarding the new managed
substance abuse care plan and its implica-
tions for Iowa physicians, call Barb Heck at
the IMS, 515/223-1401 or 800/747-3070. EH
Managed care info you can use!
Beginning in January, Iowa Medicine will
contain a special page on managed care.
The Managed care — News you can Use sec-
tion will serve as an information source
for IMS members and will contain man-
aged care information from various pub-
lications, the AMA and a variety of other
sources. Managed care — News you can
Use will contain a directory of materials
available for loan to any IMS member.
394 Iowa Medicine Volume 85 / 10 October 1995
CURRENT ISSUES
C H M I S Update
As part of the Iowa Medical Society’s ongoing effort to educate Iowa physicians about the
Community Health Management Information System (CHMIS), this CHMIS Update page will be a
regular feature in Iowa Medicine.
Progress toward the July, 1996 imple-
mentation of Iowa's CHMIS continues.
Following is a compilation of recent actions
of several subgroups appointed by the
CHMIS Governing Board:
Ethics and Confidentiality — This advi-
sory committee finalized a mission state-
ment and a public education document
concerning the release of two types of data
from patient records: 1) restricted access
data; and 2) public domain data.
Patients will not have access to data
stored in the CHMIS data repository
regarding their health care encounter.
(Patient-identifiable data from records will
never be released to any party.)
Patient data will be transmitted to the
CHMIS data repository with the patient’s
social security number as a means of fol-
lowing encounters. However, social secu-
rity numbers will be scrambled and never
released to the public. The Governing
Board believes data stored in this manner
is no longer the patient’s property, which
means patients do not have the right to
review and make corrections.
Restricted access data from patient
records will be released only with
Governing Board approval after the social
security number has been scrambled. This
data also includes zip code (five digits only),
date of birth, sex, admit and discharge dates
and procedure(s) and date(s).
Public domain data will be released,
but only in generic, demographic form.
(For example, someone’s date of birth will
be released as an age group.) The CHMIS
Governing Board believes it is virtually
impossible to identify someone from the
public domain data base.
However, all data releases will include a
number which identifies providers.
Technical — This advisory committee
has approved using the Electronic Health
care Network Accreditation Commission’s
(EHNAC) national standards as a starting
point to certify CHMIS networks. Admin-
istrative rules will be issued delineating
other Iowa criteria networks must meet.
Also, the Technical Advisory Committee
approved the Request for Proposal (RFP)
for the CHMIS data repository. Both the
network certification and the RFP will he
forwarded to the September 15 Governing
Board meeting for approval. It is expected
that the Governing Board will allow inter-
ested vendors 60 days to submit a bid. A
data repository vendor could be selected
by the end of 1995.
The cost of CHMIS
The CHMIS Governing Board decided in
June of 1995 that the party who benefits
the most from an electronic transaction
will pay the cost. This is being interpreted
to apply to the entire cost — the fee
assessed by “networks” to transmit a claim
to the insurance company — now paid by
physicians — as well as the CHMIS sur-
charge of one to four cents per transaction.
If the Governing Board continues to follow
this interpretation, the cost of electronic
submission will be reduced for physicians.
Getting prepared
It is important for physicians to realize
there are no certified networks at this
time. The IMS will publish suggestions on
how offices can meet CHMIS requirements
in an upcoming Iowa Medicine. There will
be many options for CHMIS compliance.
Even if your office manually posts charges
and payments and submits claims, it may
not be necessary to purchase a computer.
For more information on CHMIS com-
pliance or the activities of CHMIS commit-
tees, contact Ed Whitver at 800-747-3070.
M
/
\ ' /
on y out horizon July 1, 1996
YOUR representatives
on state CHMIS
committees:
CHMIS
Governing Board:
Dale Andringa, MD
Des Moines
515/241-4102
Beth Bruening, MD
Sioux City
712/233-1529
CHMIS advisory
committees:
Communications/
Education
Laine Dvorak, MD
Data Advisory
John Brinkman, MD
Ethics/Confidentiality
Charles Jons, MD
Quality Review
Elie Saikaly, MD
William Langley, MD
Technical Advisory
Mark Purtle, MD
IMS CHMIS
Committee:
Terrence Briggs, MD (chair)
IMS staff:
Ed Whitver
Barb Heck
Dean Gillaspey
Iowa Medicine Volume 85/10 October 1995 3 95
Iowa [Medicine
Legislative Affairs
AT A GLANCE
Experts at gauging pub-
lic opinion say Con-
gress is still out of favor
with citizens, with
many believing Con-
gress isn’t moving
quickly enough to trim
spending and govern-
ment. However, the
pace will pick up dur-
ing the next several
months, with lawmak-
ers voting on 13 spend-
ing bills, including a
reconciliation bill to
carry out the balanced
budget resolution.
Managed care, scope of practice issues
The IMS Board of Trustees has approved the
following priorities for the 1996 Iowa
Legislature. The recommendations came
from the IMS Committee on Legislation.
• Iowa Health Reform Transition Team
The Iowa Health Reform Transition Team
is the successor to the Health Reform Council.
The Transition Team may develop recom-
mendations as legislation. The IMS partici-
pates in transition team activities and will
evaluate recommendations as they are made.
• Coverage for Serious Mental Illness
The IMS opposes discriminatory benefit
limitations, copayments or deductibles for
the treatment of psychiatric illness under
existing health care plans, and opposes dis-
crimination in any proposed plans for nation-
al health care coverage or universal access for
the uninsured.
A wealth of governmen-
tal material can now be
found on Internet’s
worldwide web, includ-
ing the Federal Register,
Congressional Record,
US Code and other
information. The web
address is http: / /
ssdc.ucsd.edu/gpo.
• Liability Reform
Liability reform continues to be a top pri-
ority of the IMS. Efforts to reform the health
care delivery system and to contain costs will
not work without meaningful liability reform.
The Board of Trustees will assess legislative
and practice conditions in determining the
best legislative strategy on liability issues.
I IF 394 reducing the extended statute of lim-
itations for minors in medical malpractice
cases passed the House in 1995 and is eligible
for consideration in the Senate in 1996. This
initiative will continue to be an IMS priority.
• Uniform Credentialing Form
The IMS supports the initiative of the
IMGMA to develop and implement a uniform
form for use by third party payers in creden-
tialing of physicians. With the expansion of
managed care, the completion of these forms
has become an increasing burden on physi-
cians and staff.
Public Health Issues
• Universal Helmet Law
The IMS supports legislation which would
require all motorcyclists, including passen-
gers, to wear approved headgear.
• Bicycle Helmets for Children
The IMS supports legislation to require
children to wear protective helmets when
riding bicycles.
• Tobacco Free Environment
The IMS has worked with the Tobacco
Free Coalition for several years on legislation
to provide a tobacco free environment for
Iowans. Key coalition members in addition to
the IMS are the American Lung Association,
the American Heart Association and the
American Cancer Society. The coalition is
IMS POSITION ON PHYSICIANS AND
MANAGED CARE
The IMS supports the right of all physi-
cians to apply to any managed care entity
and be judged for admission based on objec-
tive criteria developed by physicians. These
admission criteria should be based primarily
on professional competence and quality of
care.
Managed care organizations should be
required to disclose to physicains the criteria
used to select, retain or exclude a physician,
including the criteria used to determine geo-
graphic distribution and number of specialty
physicians needed.
The IMS opposes legislation which would
require a manged care entity such as an IPA,
HMO, ODS or PO to admit any physician or
limited health care practitioner solely on the
basis that the practitioner is willing to abide
by the requirements of the entity. The IMS
has worked with the major payers in Iowa to
develop principles of agreement under man-
aged care.
396 Iowa Medicine Volume 85 / 10 October 1995
CURRENT ISSUES
monitoring federal activities and will develop
state legislative recommendations for 1996.
• Review HIV/AIDS Laws
An IMS Task Force has been appointed to
review state laws governing HIV/AIDS to
determine whether changes are needed. This
process will include discussion with other
organizations such as the Iowa Hospital
Association, the Iowa State Bar Association
and the Iowa Department of Public Health.
Scope of Practice/Mandated Benefits Issues
Many issues relating to expansion of the
scope of practice of limited health practition-
ers are being discussed this year. Health sys-
tem reform efforts have provided a new
forum for these issues in addition to the tra-
ditional approach of lobbying legislators for
expansion of sendees allowed under a prac-
tice act. Issues which may be debated include
the following:
• Prescribing of a “Legend” Class of Drugs by
Pharmacists
The IMS believes that allowing pharmacists
to prescribe drugs is not to the benefit of
patients. While pharmacists play an impor-
tant role as part of the health care team,
because they are not trained in diagnosis and
treatment of illnesses they should not be
granted authority to prescribe drugs.
• Expansion of Practice and Mandatory Coverage
for PAs and Nurse Practitioners
Various initiatives to expand scope of prac-
tice by reducing supervision requirements for
PAs are expected as well as require third
party payers to cover services for directly
reimbursing PAs and NPs.
Other Issues
• Limiting Copying Charges for Medical Records
In 1995 legislation was passed by the
Senate to require the department of Public
Health to adopt rules to limit the amount that
physicians and hospitals may charge attor-
neys for copies of medical records. The IMS
and the Iowa State Bar Associations have
both approved Principles of Cooperation for
Attorneys and Physicians which provide
guidelines on appropriate charges. The IMS
believes that use of such guidelines is prefer-
able to addressing the issue in state law.
• Cremation Fees for County Medical Examiners
The IMS supports an increase in cremation
fees for County Medical Examiners from the
current $ 25 to $50.
Appropriations
• Board of Medical Examiners
The IMS believes that the Board of Medical
Examiners should be fully funded through
the appropriations process. Iowa law
requires that physician license fees be set at
a level to fund the operations of the Board.
The IMS believes that revenue collected
through this mechanism should be appropri-
ated to the Board.
• Medicaid Cost Containment
Medicaid cost containment has been a major
legislative issue for the last few years.
Because of concerns about the growing
Medicaid budget, legislators have mandated
such cost containment measures as managed
care plans and requiring prior authorization
for certain prescription drugs. Even though
the budget situation has improved for the
current fiscal year, additional cost contain-
ment measures may be discussed.
• Statewide Family Practice Residency Program
The IMS supports funding for the Statewide
Family Practice Residency Program. This
program is essential for ensuring availability
of family physicians to practice in both rural
and urban areas of Iowa.
• State Medical Examiner
The IMS supports funding for the State
Medical Examiner through the Department of
Public Safety. Iowa’s medical examiner sys-
tem plays an essential role in public safety.
Support and assistance for the state and
county medical examiners will help ensure
that the system functions properly.
New Issues From Specialties and Groups — to
be discussed at November meeting
• Reduced postpartum stays
• Violence in the emergency room
• Medicaid managed mental health care
• Emergency medical services definition Dul
Many issues
related to expan-
sion of the scope
of practice of
limited health
practitioners are
being discussed
this year.
Iowa Medicine Volume 85 / 10 October 1995 397
Iowa|Medicine
Medical Economics
AT A GLANCE
Some political obser-
vers are saying that
product liability legisla-
tion (capping amounts
of punitive damage
awards and time limits
for filing lawsuits) is in
peril in Congress. The
House and Senate pas-
sed product liability bills
but left for the August
recess without appoint-
ing conferees to settle
differences. Trial law-
yers are working hard
to kill the proposals.
•
Welfare spending will be
reduced in next year’s
budget. Programs such
as Aid to Dependent
Children , food stamps
and benefits for low-
income elderly will be
trimmed at least 10%.
ITowver, welfare reform
is no sure thing. The
GOP and Clinton want
it but are far apart on
details and Republicans
are bickering among
themselves.
Final rule on Stark I self-referral law
On August 14, the Health Care Financing
Administration (HCFA) published its final
rule on the Stark I physician self-referral law
for clinical laboratory services. These regula-
tions became effective September 13, 1995.
While these final regulations only address
referrals to clinical laboratory services cov-
ered by Stark I, IICFA states that it intends to
rely on language and interpretations in this
rule when reviewing referrals for other desig-
nated health services covered by Stark II.
The deadline for commenting on the rules
is October 13; the AMA has worked with state
and specialty societies to develop comments
on the rule. The AMA also continues working
for legislative changes to physician self-refer-
ral as part of Medicare reform legislation.
Changes in earlier rules
IICFA has extensively revised the regula-
tions from earlier proposed rules to reflect
comments received. The changes include:
• revising the definition of “compensation
arrangements” to clarify that it applies to
direct and indirect arrangements;
• revising the “group practice” exemption
to require that 75% of all patient care must be
furnished through the group (unless the
group practice is located in a Health
Professional Shortage Area) and requiring an
annual statement attesting that the group has
met the test;
• revising the definition of “remuneration”
to provide that forgiveness of debts, certain
payments and furnishing of certain supplies
and devices are not considered remuneration
if they meet certain specified conditions;
• adding definitions of the following words
and terms: “clinical laboratory services”,
“direct supervision”, “hospital”, “FIPSA”,
“laboratory”, “members of the group”,
“patient care services”, “physician incentive
plan”, “plan of care” and “transaction”;
• revising the in-office ancillary services
exception to require that individuals furnish-
ing services be “directly supervised” by the
referring physician or by another physician
in the same group practice (the proposed rule
had required that services be provided by an
employee who was “personally supervised”
by these physicians);
• providing that under the in-office ancil-
lary services exception, group practices may
furnish services in a building that is used for
“some or all of the group’s clinical laboratory
services” (the proposed rule had required
that the building be used by the group prac-
tice for centrally furnishing the group’s clini-
cal laboratory services);
• adding exceptions for qualified HMOs,
and services furnished in an ambulatory sur-
gical center (ASC) or ESRD facility or by a
hospice and included in the ASC rate, ESRD
composite rate or per diem hospice charge,
respectively;
• revising the requirements relating to
publicly-traded securities;
• revising the rural provider exception to
provide that substantially all of the tests fur-
nished by the entity are furnished to individ-
uals residing in a rural area (the proposed
rule had required that the physician office
practices be located in a rural area); and
• revising several provisions regarding
“exceptions to referral prohibitions related to
compensation arrangements”.
Each physician must bill for services
The final regulations do not include an
exception for shared laboratories because
HCFA states that it would not meet the statu-
tory requirement that there be no risk of pro-
gram or patient abuse. However, HCFA does
state that “the in-office ancillary exception
could apply if each of the individual physi-
cians separately meet the supervision, loca-
tion and billing requirements” of that sec-
tion.
IICFA also makes it clear that the proxim-
398 Iowa Medicine Volume 85 / 10 October 1995
CURRENT ISSUES
ity of the laboratory to each physician’s office
is important, but that the physician may
have his or her office in a location separate
from the lab “as long as the lab is in the same
building in which the physician practices or
he or she fulfills the direct supervision
requirement by being in the office suite when
the tests are performed”.
Finally, each physician — not the lab —
must bill for services furnished to his or her
own patients.
Because of the complexity of these regula-
tions, the AMA recommends that physicians
review the rule with their legal counsel in
order to determine its impact based on their
practice arrangement. Copies of the Federal
Register containing this document may be
ordered by sending a check or money order
for $8 payable to the Superintendent of
Documents to: Government Printing Office,
ATTN: New Orders, PO Box 371954,
Pittsburgh, PA 15250-7954. Organizations
with questions regarding these regulations or
with comments on the final rule should con-
tact Michael lie of the AMA’s Department of
General Counsel at 312/464-5532.
Lawyers face increased malpractice suits
In a recent article entitled “Their Own
Petard”, the Wall Street Journal describes
the growing trend toward suing lawyers for
malpractice.
Such lawsuits once were rare, but more
clients these days see lawyers as “just anoth-
er deep pocket”. They are suing over soured
real-estate deals and disappointing trial out-
comes and post-trial judgments.
To protect themselves, lawyers are begin-
ning to take the same precautions they have
forced upon other professions. They are
screening clients more carefully, communi-
cating better, involving clients more fully in
strategic decisions and getting informed con-
sent in writing.
“For lawyers, the irony of being hoist with
their own petard is striking,” said the
Journal. “Lawyers did much to create the
litigation frenzy now plaguing them by con-
vincing people that for every setback, some-
one is to blame.” EC3
“They convinced
people that for
every setback,
someone is to
blame.”
The right procedure? The right fee?
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code and fee can prevent insurance
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Medical Management Strate-
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This offer is only valid until 11/15/95.
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Helping your practice save
time, money and worry.
Iowa Medicine Volume 85 / 10 October 1995 399
Iowa|Medicine
Practice Management
AT A GLANCE
As of July 1, 1996, HCFA
lias mandated that all
claims submitted to
Medicare Part B be in
the appropriate version
of either the National
Standard Format or
American National
Standards Institute for-
mat. Providers were
asked in mid- 1994 to
schedule their transi-
tion to one of the
approved formats in
order to avoid delays
which could force them
back to paper claims. If
you have questions , call
the Provider Auto-
mation Assistance Cen-
ter, 800/407-2067.
Last month, all IMS
members were sent a
one-page Medicare Q &
A for patients, designed
to educate senior citi-
zens about basic Med-
icare issues and what
went wrong with
financing of the pro-
gram. The Q & A is suit-
able for copying. If you
did not receive one, call
Bev Comm at the IMS,
515/223-1401 or 800/
747-30 70.
HCFA will reject truncated ICD-9 codes
As of October 1, HCFA began including
truncated ICD-9 codes (those not coded to
the highest degree of specificity) in its incom-
plete claim rejection initiative.
However, there will be a grace period until
January 1, 1996 so the physician community
can be educated, says a HCFA official. After
January 1, carriers will reject claims submit-
ted with a truncated code.
HCFA is cracking down on inadequate
diagnosis coding for several reasons:
•Carriers handle truncated codes different-
ly. Some pay claims, some develop, others
deny. HCFA wants carrier policies to be con-
sistent before the Medicare Transaction
System is implemented.
•HCFA wants to resolve the inconsistency in
carrier policy to enhance the quality of diag-
nostic data for research and policy analysis.
•More specific ICD-9 coding means better
medical decision making by physicians,
HCFA believes.
HCFA wants people to get flu shots
The Health Care Financing Administration
(HCFA) has embarked on a campaign to edu-
ate Medicare beneficiaries on the value of
annual flu shots. The message of the cam-
paign is that flu shots are very beneficial for
most senior citizens and other high risk
groups and that Medicare will pay for them.
Part of JICFA’s strategy is distribution of a
consumer brochure aimed at the Medicare
patient. Brochures are available free of
charge to physicians who serve Medicare
patients.
The IMS has brochures available. To
obtain copies, call Sherry Johnson at the
IMS, 515/223-1401 or 800/747-3070. M
Midwest Medical Insurance Company Focus on Risk Management
Confidentiality is the basis of a trusting relationship
Confidentiality forms the basis of a trusting relationship between patients and health care providers.
This relationship arises when patients trust you will respect their rights concerning personal informa-
tion. The issue is not the privilege of the health care provider, but the right of the patient.
Confidentiality extends further than releasing copies of medical records only with patient autho-
rization. There are many situations in which physicians and office staff can unintentionally breach
patient confidentiality:
•Discussing confidential patient medical care in hallways or treatment areas where it can be
overheard by other patients.
•Providing information to family members or friends without explicit patient authorization.
•Responding to telephone inquiries about a patient without proper verification of the caller’s
identity or the patient’s authorization.
•Discussing a minor patient’s treatment with a parent in a situation where the minor is entitled
to consent to their own medical treatment.
•Leaving confidential messages at a patient’s home or place of employment, or on an answering
machine.
Be aware of these inadvertent releases of confidential information and make it everyone’s job in
.
your practice to protect patient privacy.
For further information, contact Lori Atkinson, MMIC risk management supervisor, MMIC West Des
Moines office, PO Box 65790, West Des Moines, 50265, 800/798-9870 or 515/223-1482.
400 Iowa Medicine Volume 85 / 10 October 1995
CURRENT ISSUES
Yes, you should get involved!
\
Educational materials created by the IMS Task Force on
Domestic Violence are now in use across Iowa and are getting
excellent reviews from people inside and outside the medical
profession. These materials, available to any IMS member,
Break ■
include:
the
Silence
•A 27-minute commonsense video aimed at physicians but using an
^ interdisciplinary approach to solutions.
vssisSf '
% *A handbook appropriate for use in your office as a one-stop source of
1 practical information on identifying and managing victims of domestic
1 abuse. Includes information on getting a restraining order and docu-
menting abuse.
•Posters for your exam rooms or reception area.
star
•Hotline cards containing the IMS domestic violence logo and the
statewide domestic violence hotline.
f
To get materials or to learn more about the IMS campaign
Begin the Cure
against domestic abuse, call Chris McMahon at the IMS, 515/223-
1401 or 800/747-3070.
Don't Leaue the
Accuracy of your Data
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encounter forms
inventory & chart tracking
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Cedar Rapids, IA 52402-5079
(319)366-3326 1 -800-332-5245 fax: (3 1 9) 366-3752
Iowa Medicine Volume 85 / 10 October 1995 401
Iowa| Medicine
Newsmakers
AT A GLANCE
Dr. Timothy Peterson,
Des Moines emergency
medicine physician, has
received the 1995 “911
Team ” Award from the
American College of
Emergency Physicians
(ACEP). Award recipi-
ents are honored for im-
mediate efforts, above
and beyond the call of
duty and their constant
state of readiness to ad-
vance and promote the
ACEP's advocacy pro-
gram on the grass roots
level. Dr. Peterson was
specifically honored be-
cause his “work with
Congressman Greg Gan-
ske and his staff is an
outstanding example of
the dedication and per-
sistence that character-
ize a 9 11 Team member."
IMS Task Force receives praise
Dear Editor:
I congratulate the IMS Task Force on Domes-
tic Violence on the excellent job it has done on
the videotape for physicians and the physician
handbook. The physician handbook is a valu-
able asset for all physicians and I strongly
encourage all members of the Iowa Medical
Society to carefully re-
view it.
Increased aware-
ness and a few simple
tools in better identi-
fying victims of domes-
tic violence have been
valuable in my prac-
tice.— Janice Kir sell,
MD, Women’s Health Center, Mason City
Dear Editor:
Thank you for the interest the Iowa Medical
Society has shown for the problem of domestic
abuse in our society. Iowa Medicine did a
wonderful job of bringing the issue to the atten-
tion of the medical community last winter. And
now, your video is particularly impressive!
Again, thank you for your interest and for
your willingness to be part of the solution. —
Donna Walgren, director, Children & Families
of Iowa, Des Moines
Awards, appointments, etc.
Dr. David Hussey, professor and director of
the Division of Radiation Oncology at UI Hospi-
tals and Clinics, was recently named treasurer
of the American Radium Society at the society’s
annual meeting in Paris. Members of the Linn
County Medical Society have elected new offic-
ers: Dr. Steven Eyanson. president; Dr. Wilson
Strong, president-elect; Dr. Thomas Hansen,
vice president and Dr. John Wollner, secre-
tary-treasurer. Dr. Francois Abboud, profes-
sor and head of internal medicine at the UI
Letter
to the
Editor
College of Medicine, received the American
Heart Association’s prestigious Gold Heart
Award during the association’s 47th annual
meeting in Dallas, Texas. Dr. Abboud served as
president of the AHA from 1990 to 1991 and has
been involved with the organization since 1958.
Currently he is a member of the Iowa Affiliate
Board of Directors. Dr. Erin Herndon, Des
Moines, is the director of the newly-opened Mae
E. Davis Free Medical Clinic. The clinic is one
of five Healthcare Access Network clinics in
Iowa providing free health care to insured and
uninsured Iowans. Dr. Jacquelyn Ryan, Dr.
Nicolas Shammas and Dr. William Witcik re-
cently joined Cardiovascular Medicine, P.C.,
Davenport. Dr. David Kragenbrink has joined
Drs. David Kemp, Keevin Franzen and R.
Michael McGill in pediatric practice in
Dubuque. Dr. Sonia Sather, third-year resi-
dent in the Cedar Rapids Family Practice Resi-
dency Program, has been named recipient of
the 1995 Mead Johnson Award for Graduate
Education. Two recent graduates of the Cedar
Rapids Family Practice Residency Program are
joining Cedar Rapids practices: Dr. Nancy
Angenend has begun medical practice with Dr.
Carla Schulz and Dr. Daniel Vanden Bosch is
joining Drs. Carlton Lake, Brian Lindo, John
Roof and Robert Swaney. Dr. Alan Bollinger
has been appointed director of emergency ser-
vices at Broadlawns Medical Center where he
has assisted in the department for the past four
years. Dr. Janet Schlcchte, professor in the UI
College of Medicine, Department of Internal
Medicine and director of the UI General Clini-
cal Research Center, received the 1995 Laure-
ate Award from the Iowa Chapter, American
College of Physicians. Dr. Charles Lutz, associ-
ate professor in the Department of Pathology,
has been named to the editorial boards of the
Journal of Immunology and the Journal of
Dental Research. Dr. Michael Pfaller, profes-
sor in the Department of Pathology, has been
appointed to the editorial board of the journal,
An timicrobial Agen ts and Chemotherapy. Dr.
R. Stephen Cooke has joined Linn County
402 Iowa Medicine Volume 85 / 10 October 1995
CURRENT ISSUES
Anesthesiologists, P.G. Dr Daniel Fabiano (or-
thopedics) and Dr. Barry Scherr (family prac-
tice, rheumatology) have joined Dr. David Field
in medical practice in Dubuque. Dr. Jonathan
Knight has joined the Medical Associates
Elkader office. Dr. Paul Seebohm, UI professor
emeritus in the Department of Internal Medi-
cine, has been honored by the American Acad-
emy of Allergy and Immunology for his service
to the organization as a delegate to the AMA
from 1973-94.
New members
Ames
i Richard Stopps, MD, obstetrics/gynecology
'Mark Taylor, MD, general surgery
' Belle Plaine
i Deborah Janicki, MD, family practice
Cedar Rapids
Leslie Kramer, DO, dermatology
l Juanita Murawski, MD, psychiatry
Simon Wall, MD, psychiatry
Cherokee
Timothy Conrad. DO, resident
Des Moines
David Drake, DO, psychiatry
Joannie Franklin, MD, family practice
Roger Gan field. MD, family practice/anesthe-
siology
Martha Senneff, MD, internal medicine/car-
diovascular diseases
Brad Smith, DO, general surgery
Fred Stansbury, DO, internal medicine/oncol-
ogy
Catherine Truesdell, DO, pediatrics
; Dubuque
Mark Westfall, DO, emergency medicine/in-
ternal medicine
Elkader
Lvnette Lamp, MD, family practice
j
Iowa City
Carlyn Christensen-Szalanski, MD, pediatrics
Eileen Comstock, MD, resident
Harriet Echtemacht, MD, resident
Matthew Howard, III, MD, neurological sur-
gery
Gene Lariviere, MD, general surgery
Edward Rieeiardelli, MD, plastic surgerv/oto-
laryngology
Ashish Sanon, MD, ophthalmology
Thomas Simpson, MD, resident
Theodore Wynnchenko, MD, resident
Osceola
George Fotiadis, MD, family practice
Alan Patterson, MD, family practice
Oskaloosa
Randall Hart, DO, family practice
Sergeant Bluff
David Sly, DO, family practice
Sheldon
Robert Thorbrogger, MD, radiology
Sioux City
Thomas Clark, DO, neurology
Benton Davidson, MD, neurology
Joe Kinzey, MD, family practice
Daniel Samani, MD, orthopaedic surgery
Spirit Lake
Jerome Perra, MD, orthopedic surgery
Waterloo
Cassandra Foens, MD, radiation oncology
Lawrence Furlong, MD, diagnostic radiology
Baz Ilundal, MD, internal medicine
West Burlington
James Milani, DO, family practice
West Des Moines
Linda Lehman, MD. ophthalmology
John Nassif, MD, ophthalmology
David Saggau, MD, ophthalmology
Deceased members
Annette Fitz, MD, 62, internal medicine,
Iowa City, died July 13
Mark Armstrong, MD, 74, internal medicine,
Iowa City, died July 1 1
Michael Bonfiglio, MD, 78, life member,
orthopedic surgery, Iowa City, died June 13
Clyde Meffert, MD, 94, life member, family
practice, Cedar Rapids, died September 3
Seth Walton, MD, 88, life member, general
surgery, Hampton, died June 14 [0
If you have news
for this
“Newsmakers”
column, send it to
Iowa Medicine ,
1001 Grand Avenue,
West Des Moines,
Iowa 50265.
WeTd like to hear
from you.
Iowa Medicine Volume 85/ 10 October 1995 403
Iowa | Medicine
FEATURE ARTICLE
Iowa physicians and community hospitals . . .
“ 1 Common interests
How can payer demands for reduced costs be met while
maintaining strong cooperative ties between physicians and
Iowa hospitals? The surest strategy may be vigorous
physician-owned delivery systems which can retain market
share which hospitals by themselves could lose to larger centers.
Cooper Parker
Cooper Parker is a
principal with Physician
Network Management,
Inc. (PNMI) PNM1 has
offices in Des Moines and
Oklahoma City.
The pressure to reduce cost is mounting on
physicians and hospitals throughout the
country and Iowa is no exception.
Responses to these pressures are coming
thick and fast; physicians are proposing to
provide more services outside the hospital
setting, thus avoiding its fixed costs and
lowering the costs of procedures. Hospitals
are acquiring physician practices and
attempting to form PIIOs, but many payers
are skeptical about their success because
neither understands the extent to which
these organizations must be operational and
not merely marketing entities.
Iowa’s hospitals and physicians, largely
because they share the same community
interests, have not been victim to the
polarization which characterizes these
relationships in other states.
Urban hospitals have sought to
expand by purchasing outlying
physician practices and surgeons
have moved significant portions of
their practices to physician-owned
facilities. However, a desire to
preserve the peace prevails
between the two, though the peace may be
uneasy at times.
How can payer demands be met while
maintaining the strong cooperative ties
between physicians and hospitals? It is
possible that the surest strategy may be the
emergence of vigorous physician-owned
delivery systems which have the potential of
retaining market share which the hospitals,
by themselves, will surely lose to larger
medical centers.
Payer dissatisfaction
Until this summer, writers were describing
the failed Clinton administration initiative as
the most recent attempt to change the
system by which medical services are
organized, delivered, managed and paid, but
The surest strategy r,rovit*ers can ta^e 110 comf°rt that
the government pressure is off.
may be the
emergence of
vigorous,
physician-owned
delivery systems.
Senate Republicans have just
introduced their version of health
care reform. Although this
proposal is no where near as
extensive as last year’s, it contains
many of the same flaws.
404 Iowa Medicine Volume 85 / 10 October 1995
FEATURE ARTICLE
Government initiatives aside, the
marketplace has and will continue to exert its
own demands for change, requiring action
and response by physicians and hospitals. We
read about the national purchaser coalitions
which, through joint contracting, exacted
discounts from California lIMOs and we know
that the same thing is happening — though
with less dramatic success — in Iowa.
We hear of payer dissatisfaction with
unseemly profits being stockpiled by IIMOs
while physicians and hospitals are squeezed
and overall costs continue to climb.
Corporate America is exerting pressure on
insurers’ rates (particularly IIMOs), declaring
their unwillingness to continue contributing
to the IIMO bottom line at the expense of
their own. This turn of events, however, is
only likely to increase the downward pressure
on physician and hospital fees as IIMOs
attempt to decrease costs but not profits by
decreasing medical costs.
Trend toward concentration of power
Compounding this problem is the trend we
see toward concentration of power in the
hands of a few insurance companies. Some
industry analysts expect to see, within the
next five to seven years, the concentration
(by acquisition and merger) of power in the
hands of 10-12 IIMO giants.
Alongside government and market
pressures, we see activity in Iowa which links
hospital systems and attendant medical
practices into competing systems. Hospitals
seek to retain market share by becoming a
part of a more comprehensive system, thus
keeping those services it provides well and
appropriately within the community and
making wider services available to
community members at reduced prices.
Quality and price considerations are
addressed in a way which benefits the
community.
Need for physician-oriented options
What of physicians’ interests? In such an
arrangement, whether it is a single hospital
PIIO or a multiple hospital/physician system,
it is fairly easy to distinguish the hospital
interest and to see how hospital resources are
brought to bear to further hospital interests.
On the physician side of the equation, the
picture is not so clear. The author was closely
involved in the late 1980s in Hospital Choice
Health Plan, an Ohio IIMO owned by 23
hospitals in central Ohio, which included
their medical staffs. The strategy was to
preserve market share by linking rural
hospitals and their staffs with Columbus
hospitals and medical staffs.
While successful enough to attract
favorable attention from Nationwide
Insurance, leading to its acquisition by
Nationwide, there were problems. An
important one was that hospitals had staff
and other resources to protect their interests
but physicians did not and suffered
continued
On the physician
side of the
equation, the
picture is not so
clear.
Iowa Medicine Volume 85 / 10 October 1995 405
Iowa Medicine
FEATURE A R T J C L E
continued
Such organizations
are not intended to
replace PHOs. In
fact, the physicians
most committed to
them are also
usually the most
active in their
PHOs.
significant but unintended losses as a
result. Hospital rates protected their fixed
costs but physician capitations had no
experiential basis and proved inadequate to
support the utilization of medical services
which occurred.
Physicians are fully occupied with busy
practices and are not organized to deal with
all the requirements of sophisticated
negotiations with managed care entities or
the demanding intricacies of overseeing an
IIMO.
Establishing a strong role for physicians
However, the environment is changing
rapidly and dramatically. Recently, the AMA
announced formation of its ‘private sector
advocacy and support team’, whose function
is to “help doctors finance their own health
plans to battle for patients in the burgeoning
managed care market”.
Such organizations are multiplying
everywhere, most notably in New Jersey,
New York and Connecticut. PNMI has just
recently completed a market audit and
written a business plan for such an entity in
Houston, Texas and has been engaged to do
similar work for a physician-owned group in
the Midwest.
It is also worth noting that the size of the
groups varies widely. The largest group with
which the author has been associated is the
6,000 physicians of the Harris County
Medical Society in Houston, Texas; the
smallest is a nine-physician organization in
South Texas. The common link is not size
but commitment and willingness to stay the
course.
Such organizations are not intended to
replace PHOs. In fact, the physicians most
committed to them are also usually the most
active in their PHOs. They simply see the
need for a strong and stable physician-
oriented option to offer the marketplace.
Such entities establish a strong role for
the physicians as an advocate for patients
and as a clinical decision-maker. They also
exemplify the possibility of effecting cost
management through means other than
reducing the physician fee schedule.
Physician-owned delivery systems demand
certain conditions which include:
• Physician willingness to manage
utilization.
• Physician willingness to forego high
profits in return for a reasonable fee
schedule and return of clinical control.
(There must, of course, be an adequate con-
sideration in the premium for ad-
ministration of the plan, including
utilization/management quality assurance,
claims administration, marketing and
product design.)
• Physician willingness to finance the
enterprise and bear its risks.
• Physician willingness to operate a small
business (grandiosity is a fatal flaw).
406 Iowa Medicine Volume 85/10 October 1 995
FEATURE ARTICLE
Two strong partners
How can such an organization help rural
hospitals if they enter the marketplace in
competition with the hospital’s PI 10?
Both entities seek to strengthen the other,
but we have seen how physician resources
are no match for those of even the smallest
hospital. Two strong partners are more
helpful to each other than a venture where
one is weaker than the other.
Payers are looking for local solutions to
their health care problems. In all the market
audits done by PNMI, payers say they would
much rather deal with local doctors and
hospitals than with distant insurers who are
taking dollars out of the community.
Physicians have a case to make to them
about the danger of continued erosion of the
integrity of medicine by insurers and HMOs.
If this case is persuasive, local hospitals will
also benefit. Hospital Choice Health Plan
demonstrated what can happen to preserve
the stability of local hospitals when their
medical staffs organize themselves as
financially responsible entities willing to take
risks.
We are now seeing how local hospitals
benefit when physicians take the additional
steps of becoming independent and
approaching the market as strong, vibrant
alternatives to delivery systems which are
causing unrest among both physicians and
payers. ED
TTV
A
,
Mercy-Harvard Executive Program
in Health Policy and Management
Fourth Annual
An advanced management program for physicians and
health care executives designed to prepare Iowa’s health
care leaders for the future. Each day-long session is pre-
sented by faculty members from the Harvard School of
Public Health.
Sessions
The Changing Health Care Organization
Biostatistical Methods in Medicine
Allocation of Health Care Resources
Health Law and Risk Management
Health Care Information Systems
Health Care Policy: Development, Passage,
Implementation
1996 Dates
January 19 March 15 May 17
February 16 April 19 June 14
Fridays (8:30 a.m. -4 p.m.)
Who should attend
Physicians • Health Care Administrators
Lawyers • Nurses • Insurance Executives
Human Resource Managers
CME’s/CEU’s offered
For a brochure call: 515-222-7255
‘
Iowa Medicine Volume 85 / 10 October 1995 4 07
i ( > w ;i| Aieuiciiic
GME Seminars
Cardiology
AT A GLANCE
Advertise your continu-
ing medical education
seminars or workshops
in this section by call-
ing Jane Nieland or Bev
Corron at the Iowa Medi-
cal Society, 515/223-
1401 or 800/747-3070,
fax 515/223-8420 or
send copy and payment
to Iowa Medicine, 1001
Grand Avenue, WestDes
Moines, Iowa 50265.
Cost is S25 per insertion
up to 10 lines. Deadline
is the first of the month
preceding publication.
Advanced Arrhythmias: Therapies and Tech-
nologies
November 7, 1995
Mercy Medical Center, Cedar Rapids, Iowa
AMA Category 1, 6 credit hours
Contact Mercy Medical Center, Education De-
partment, 701 10th Street S.E., Cedar Rap-
ids, Iowa 52403, 319/398-6143
General Interest
Bridging Science and Program
October 22-25, 1995
Des Moines Convention Center, Des Moines,
Iowa
850, 16 credit hours
Hosted by Centers for Disease Control and
Prevention, National Center for Injury Pre-
vention and Control and University of Iowa
Injury Prevention Research Center
Contact University of Iowa Conference Center,
319/335-3231
Internal Medicine
Diabetes 1995: A Harvest of New Ideas
November 17, 1995
Botanical Center, Des Moines, Iowa
Speaker: Frank Vinicor, MD, director of Diabe-
tes Translation, Centers for Disease Control,
president of the American Diabetes Associa-
tion
Contact Iowa Methodist Medical Center, 1200
Pleasant, Des Moines, Iowa 50309, 515/241-
5074
Fibromyalgia and the Link with Chronic
Fatigue Syndrome Seminar
November 15, 1995
Ilawkeye Community College, Waterloo, Iowa
860, AMA Category 1 , 7 CMEs/0.8 CEUs ( Iowa
Board of Nursing Provider #11)
Speakers: Mahammad B. Yunus, MD; Farid
Manshadi, MD; William Collinge, PhD
Contact Staff Development, Covenant Medical
Center, Waterloo, Iowa, 319/236-4058
Neurology
Neurology for the Non-Neurologist
December 6-8, 1995
Swissotel Chicago
8425, Category 1, 20 CMEs
Contact Office of Continuing Medical Educa-
tion, Rush-Presbyterian-St. Luke’s Medical
Center, 600 S. Paulina, Suite 520, Chicago,
Illinois 60612, 312/942-7095, fax 312/942-
2000
CLARKSON MEDICAL
LECTURE SERIES
November 17, 1995
8:00 a.m. - 5:00 p.m.
Advances in
Primary Care:
Building on the
Legacy
Clarkson Hospital
Omaha, Nebraska
(Storz Pavillion)
For more information call
1-800/647-5500, ext 3039
402/552-3039
Iowa I Medicine
SCIENCE AND E D U C A TION
The Journal
of the Iowa Medical Society
Alzheimer’s disease: the role of tacrine therapy
# Gerald Jogerst, MD
As the size of the elderly population expands,
dementia becomes an ever-growing health
problem. Dementing illness demands an
increasing share of public health care
resources and health care dollars. The elderly
population of the U.S. makes up 12% of the
national census. By the year 2030 it will
account for 20%. Approximately 5% of those
over age 65 are severely demented and an
additional 10% exhibit some degree of intellec-
tual compromise. Fifteen to 30% of those over
age 80 suffer from a dementia. Since
Alzheimer’s disease is the most common cause
of dementia, there is an increasing need for
primary care physicians to diagnose
Alzheimer’s disease and to properly utilize
i therapies for dementing illnesses. Tacrine
hydrochloride is the first drug released by the
FDA for the treatment of cognitive deficits
i associated with Alzheimer’s disease.
Dementia is not a part of normal aging, and
patients presenting with dementia should be
thoroughly evaluated regardless of age.
Dementia is an acquired, sustained decline in
intellectual function without alteration of con-
sciousness. There is deterioration in at least
two of the following spheres of intellectual
function: memory, language, visual-spatial
skills, personality and cognition (which
includes the ability to abstract and calculate).1
Alzheimer’s disease accounts for approximate-
ly 50% of all dementia cases, vascular demen-
tia 5% to 20% and combined Alzheimer’s
dementia and vascular dementia for 10% to
15%.2 The onset is typically after age 65 and
the disease is gradually progressive, leading to
| death in 6 to 12 years from time of diagnosis.1
Diagnosing Alzheimer’s disease
Specific clinical features should be present
to diagnose Alzheimer’s disease. These find-
ings include progressive disturbance of mem-
ory, both recent and remote, as well as
deficits in language, calculation, judgment
and constructional skills.4 The neurologic
examination remains normal until the termi-
nal stages when motor abnormalities appear.
The aphasia of Alzheimer’s disease includes a
fluent output, poor auditory and reading
comprehension, preserved repetition and
intact ability to read aloud. Behavioral
changes include indifference and delusions,
but severe depression is rare.
Routine laboratory studies contribute little
to the diagnosis of Alzheimer’s disease. MRI
scans showing small hippocampus and tem-
poral horns of the lateral ventricles may dis-
tinguish mild Alzheimer’s disease from nor-
mal age-matched controls.5 Functional
neuroimaging with positron emission tomog-
raphy using fluorodeoxvglucose reveals bilat-
eral parietal lobe hypometabolism early in
the course of Alzheimer’s disease. Neuro-
chemical studies reveal loss of cholinergic
enzymes from the cerebral cortex. The
cholinergic involvement results from atrophy
of the nucleus basalis of Mevnert which is a
sub-frontal cholinergic nucleus with exten-
sive cortical projections. Norepinephrine,
somatostatin and serotonin are also depleted
in Alzheimer’s disease. Since the symptoms
of Alzheimer’s disease are thought to be due,
at least partly, to the depletion of acetyl-
choline in the brain, drugs are being devel-
oped to alter the effects of this depletion.
Pharmacological strategies to address the
depletion of acetylcholine activity include
loading patients with precursor substances
necessary for acetylcholine synthesis.
Lecithin has been used for precursor loading
and has provided no benefit, but substantial
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
October 1995.
Ger.\ld Jogerst, MD
Dr. Jogerst is with the
Department of Family
Practice at the UJ College
of Medicine, Iowa City.
Iowa Medicine Volume 85 / 10 October 1995 409
Iowa | Medicine
Alzheimer’s disease: the role of tacrine therapy
continued
gastrointestinal side effects.6,7 Physostigmine,
an anticholinesterase, has been associated
with mild memory improvement in some
patients.8 However, no overall gain in the
activities of daily living accompanied the
memory benefits.0'12 Another strategy is to
use muscarinic receptor agonists such as
bethanechol.13 This too has proven unsuc-
cessful.14 A newer therapy under investigation
is the use of the monoamine oxidase B
inhibitor, selegiline hydrochloride (Eldepryl),
to reduce the oxidative stresses on at-risk
cells and therefore delay cell destruction and
acetylcholine depletion.15
Tacrine therapy in clinical trials
Tacrine hydrochloride is the first drug
released by the FDA for the treatment of cog-
nitive deficits associated with Alzheimer’s
disease. It is an orally bioavailable, centrally
active, reversible cholinesterase inhibitor.
Presumably, it increases acetylcholine con-
centrations in the cerebral cortex through
slowing the degradation of acetylcholine
released by still intact cholinergic neurons.
Tacrine also blocks the uptake of dopamine,
serotonin and norepinephrine and inhibits
monoamine oxidase activity. It does not alter
the course of the underlying dementing
process. The drug effects may lessen as the
disease process advances and fewer choliner-
gic neurons remain functionally intact.
Clinical trials carried out on tacrine
included a double-blind, placebo-controlled
study of 632 patients with mild to moderate
mental impairment probably caused by
Alzheimer’s disease. The final six weeks of
the trial was limited to 215 patients who
demonstrated initial response to the drug. In
this “enriched” population, patients treated
with tacrine had smaller decline in memory
and quality of life measures than the placebo
group. However, clinicians could not detect a
difference between patients taking tacrine or
placebo. A secondary finding was a slower
decline in instrumental activities of daily liv-
ing in the tacrine treated group. A 12-week
trial of 468 patients with mild to moderate
impairment probably due to Alzheimer’s dis-
ease demonstrated that patients on 40 mg
per day for six weeks showed improvement
in cognitive testing.17 Individuals who took 80
mg per day for the second six weeks showed
improvement in cognitive testing as well as
clinical global ratings, meaning that clini- i
cians could detect a difference. The cognitive
tests used were the cognitive component ol
the Alzheimer’s Disease Assessment Scale
(ADAS-Gog) and the clinician-rated Clinical
Global Impression of Change.18'10 There were,
no statistically significant changes in Mini-
Mental State Examination (MMSE) scores.211
The most recent clinical trial evaluated
the benefits of tacrine dosages up to 160
mg/d over 30 weeks.21 Six hundred fifty-three
Alzheimer’s patients with MMSE scores of 10 j
to 26 were studied in an intent-to-treat,
analysis. The eligible patients were otherwise
healthy. Patients treated with 160 mg/d of
tacrine showed significant improvements on
objective cognitive tests, quality-of-life
assessments and clinician/caregiver-rated
global evaluations. Lower dosages of tacrine
resulted in marginal improvements. A total of
58% (384 patients) withdrew from the study
before week 30, 74% (285/384) because of
adverse effects. Only 28% (67/239) of the,
patients randomized to the 160 mg/d treat-
ment arm were able to remain on the drug at
30 weeks. Those patients who were able tci
tolerate 160 rng/d improved on the ADAS-Cog
by an amount equivalent to six months ol
deterioration in the course of Alzheimer’^
disease.22
The most common adverse effect of
tacrine is an increase in the serum alanine
transferase (ALT). This occurs in nearly 50%;
of patients who take the drug and approxi-
mately 25% have an increase three or more
times the upper limit of normal. 2,1,24 Approxi
mately 90% of these elevations occur withir
the first 12 weeks after initiation of treatmen:
and most return to normal within six week;
after discontinuation of the drug.24 Other side
effects include nausea, vomiting, diarrhea,
heaelache, myalgias and ataxia.
Tacrine appears to slow the decline oi
improve test scores in a minority of patient; !
with mild to moderate Alzheimer’s disease
No evidence exists in controlled trials tha
tacrine therapy leads to a substantia
improvement in function. The drug can causy
hepatic injury. Compliance may be a problen
because of the need to take it four times ; $
day. The cost is approximately 8120 for a on<
month supply. Laboratory costs for the firs I
four months of therapy are estimated at 880 if
410 Iowa Medicine Volume 85 / 10 October 1995
SCIENCE AND EDUCATION
90 per month and are reimbursed through
Medicare. The benefits of tacrine for an indi-
vidual patient can only be demonstrated by
an adequate trial. In light of these findings
what prescribing criteria should be used for
this drug?
Criteria for initiating tacrine therapy
For individuals or families requesting
tacrine, the following criteria for initiation of
therapy seem reasonable. First, establish a
diagnosis of Alzheimer’s disease, mild to mod-
erate in severity. This would exclude patients
who are institutionalized because of severe
cognitive and functional deficits related to
Alzheimer’s disease. Documentation of cogni-
tive impairment should include a MMSE, clock
drawing, and/or formal neuro-psvehological
testing?5 Second, functional status which
includes target deficits or problem behaviors
identified by the patient’s caregiver or physi-
cian should be evaluated on a regular basis.
Third, since benefits may increase with higher
doses, a commitment should be made by the
patient and caregivers for a full trial of tacrine.
The dose of tacrine is started at 10 mg Q.I.D.
and increased as tolerated by 10 mg per dose
every six weeks to a maximum of 40 mg Q.I.D.
Finally, a visit to the physician every six weeks
during dose escalation is necessary to review
response and side effects of therapy.
Monitoring of therapy should include a
baseline general chemistry screening that
includes an ALT level. Obtain weekly ALT
levels during dose escalation for not less than
18 weeks and every three months thereafter.
For those patients without significant ALT
elevation (less than 2 times normal) recom-
mended interval for obtaining ALTs has
recently changed to every other week for the
first 16 weeks of therapy. An objective mea-
sure of cognitive function should be done pri-
or to initiation of therapy as well as at six
months. This testing can be performed by the
prescribing physician or by physicians or
psychologists with advanced training in the
assessment of dementing illness. Caregivers’
subjective impression of change should be
reviewed at six week intervals. Adverse
effects should be reviewed at each visit.
During the escalation phase of tacrine
therapy, ALT levels less than three times the
upper limits of normal should not delay
increased dosing. If the levels reach between
three and five times the upper limits of nor-
mal, reduce the dose of tacrine by 40 mg per
day. Then resume dose escalation once the
ALT returns to normal limits. Tacrine should
be stopped for ALT levels greater than five
times the upper limit of normal. The patient
may then be re-challenged with 10 mg QID
and follow the original dose escalation sched-
ule. Insufficient data exists on the risk of re-
challenging patients with ALT levels greater
than 10 times the upper limit of normal.
Another indication to discontinue tacrine is
clinical jaundice, confirmed by significant
elevations of total bilirubin, greater than 3
milligrams per deciliter.
Conclusion
Tacrine is the only agent approved for the
treatment of Alzheimer’s disease. A small
group of Alzheimer’s patients tolerate the
drug and show improvement in cognitive
function or in clinician and caregivers’ gener-
al impression of the course of the disease.
There is no evidence from controlled trials
that the use of tacrine leads to substantial
functional improvement. The risk of hepatic
injury requires weekly monitoring of liver
functions test during the initial course.
Tacrine is indicated in mildly to moderately
severe Alzheimer’s disease if the patient is
willing to be closely monitored and the
patient and family understand the drug’s ben-
efits and risks. There is no indication for
tacrine in severely demented patients,
including those admitted to nursing homes
because of their cognitive deficits.
References
References noted in this article are avail-
able from the authors or the editors of Iowa
Medicine. E]
Iowa Medicine
Volume 85 / 10 October 1995
411
You'll know
you're putting down roots
when ■*■■■
...You're a "regular" on our nationally ac-
claimed biking and cross-country skiing trails
in Monroe, Wisconsin ... You audition for a
part in our theater guild productions ... You
practice soccer, swimming, basketball orTae
Kwon Do with your family at the local "Y"...
You coax your favorite perennials to bril-
liance beside a lawn as lush as the farms that
cover 90% of the county.
The coveted standard of living in our com-
munity of 10,000 complements the profes-
sional environment that awaits you at The
Monroe Clinic— a consolidated and inte-
grated healthcare facility combining a new
1 14,000 sq. ft. clinic adjoining a state-of-the-
art, 140-bed acute care hospital with 24-
hour ER coverage. Here and in branch clinics
in south central Wl and northwestern IL, our
50+ physician multispecialty group provides
family oriented health care. You can play a
key role as a BC/BE physician in:
• Family Practice
• Internal Medicine
• Dermatology
• Emergency Medicine
We offer comprehensive
benefits and productivity
based pay with excellent
1st year income
guarantee ; freedom from
office management and
buy-in costs; potential for
researchlacademic
appointments, and a
prime location just two
hours from Chicago and
Milwaukee and one hour
from Rockford, IL,
Madison, Wl and
Dubuque, IA. We also
have opportunities at our
clinics in nearby New
Glarus, W I and Freeport,
IL. Call 800-373-2564 or
send CV to: Physician
Staffing Specialist,
THE MONROE CLINIC,
51 5 22nd Ave., Monroe,
Wl 53566. Or fax resume
to 6081328-8269. EOE.
The Monroe Clinic
A proud caring tradition
Franciscan Skemp
Healthcare
MAYO HEALTH SYSTEM
La Crosse, Wisconsin- Exciting opportunities are
available for BE/BC physicians in the following areas
• Family Practice • Urgent Care • Pulmonology
• Cardiology • Neurology • Neurosurgery
• Orthopedics • Neonatology
• Emergency Medicine
Franciscan Skemp Healthcare, an integrated delivery
network, serves a population base of 350,000. We
include three hospitals and 12 clinics with over 100
active medical staff members.
La Crosse is located in scenic Mississippi River bluff
country with excellent fishing, hunting, boating. Ideal
family-oriented environment. Good public and private
schools.
Contact:
Tim Skinner, M.S.Ed., or Bonnie Nulf
Franciscan Skemp Healthcare
800 West Avenue South
La Crosse, Wl 54601
Phone: (800) 269-1986
Fax: (608) 791-9898
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Iowa I Medicine
THE EDITOR COMMENTS
A letter to your spouse
The first bond of society is marriage (Prima
societas in ipso conjugio est).
Cicero
With this ring I thee wed , and with all my
worldly goods I thee endow.
Book of Common Prayer
An article entitled “Have you written to
your spouse lately?” by Raymond S.
Kreienkamp (an attorney) in the
August 1995 issue of St. Louis Metropolitan
Medicine caused me to reflect upon responsi-
bilities to our spouses. The message involves
the responsibility to prepare our spouses so
that our passage from this life leaves fewer
questions and problems for the survivor.
Estate planning consists not
only of preparing a will or trust,
but informing your spouse of
numerous faeits of desires of the
estate and the location of assets.
Each spouse should prepare a let-
I
ter to the other spouse (or another
family member if there is no
spouse) providing a myriad of
informational data. The letter will assist the
survivor with certain decisions that will need
to be made during the first several weeks
after the death. No professional assistance is
required; just a personal letter of love and
assistance.
Few people like to think about death, least
of all adequately plan for that event. Howev-
er, the letter in question should include per-
sonal desires for funeral arrangements. Obvi-
ously, the letter does not constitute a will
and should be readily available rather than
being locked in a safe box at the bank. Each
spouse or other responsible survivor should
know of the existence and the location of the
letter.
Following are items that should be includ-
ed with the letter: estate planning docu-
ments, names of advisors, data on life
insurance, government death benefits, hospi-
talization insurance, financial data, balance
sheets, bank account numbers, safe combi-
nations, investments, outside loans and
investments, home mortgage and abstract,
tax files, credit cards, licensure information
and location of auto titles, other assets, debts
owed, allocation of personal items
to selected persons, etc. The let-
ter should be reviewed annually.
To have prepared for your
demise to ease the burden on
your spouse should constitute a
final declaration of love. If we
concur with Cicero that the first
bond of society is marriage, our
words to our surviving spouse seal that bond
with finality.
If you would like to have a copy of
Kreienkamp’s paper call or write to me in
care of Iowa Medicine. ^
No professional
assistance is
required; just a
personal letter
of love and
assistance.
M\rion Alberts, MD
Iowa Medicine Volume 85 / 10 October 1995 41,3
You respond to them.
You support them.
You fight
for them.
The AMA responds,
supports ana fights
for you.
Everyday, you help ease suffering, heal patients and save
lives. It is an ennobling calling. The AMA shares
your values. Your patients’ health is our highest priority,
too. As the world’s preeminent medical organization, our
300,000 member physicians work together for the benefit
of all Americans. We speak out on behalf of patients and
physicians with a single, powerful voice. We advance the
art and science of medicine. We promote ethical, educa-
tional and clinical standards for the profession. We are
partners in a lifelong crusade. When you become
an AMA member, you are expressing your commitment to
patients, to the profession, and to resolving the great
health care issues of our time. Join us now. Call your coun-
ty or state medical society, or AMA at 800 AMA-32 1 1.
American Medical Association
Physicians dedicated to the health of America
Together, we are the profession.
Iowa 1 Medicine
PHYSICIAN LEARNER
Learning in a
health care team
Note: This is a second of three articles on
in terd iscipli nary CME.
Most practicing physicians are the
product of an educational hierarchy
in medicine. That hierarchy is struc-
tured by seniority and to a lesser extent by
specialty. The entrance point is the first year
of medical school; the education process typ-
ically occurs for at least seven years with the
completion of residency. Throughout those
years the physician-in-training acquires
knowledge, skills and judgement, becoming
part of a teaching hierarchy that includes the
scientific and clinical faculty.
A revelation for many medical students is
the realization during their training that
their learning is enriched by clini-
cians other than physicians. How
many of us gained our most useful
insights into family function from
a hospital social worker? How
many of us acquired an apprecia-
tion of the assessment and man-
agement of pain from an experi-
enced nurse? How many of us
learned the rudiments of extremity rehabili-
tation from a physical therapist? How many
of us learned about dietary options in com-
promised patients from a nutritionist? The
answer to these questions is evident.
Our abilities as physicians have been
enriched through work and communication
with other health care professionals. Such
experiences of course do not cease when we
complete our formal training, but they con-
tinue throughout active clinical practice.
It is then remarkable that we sometimes
learn of physicians’ reluctance to participate
in organized CME activities that also include
other health care professionals as partici-
pants. Some physicians may not want to
acknowledge that their knowledge or skills
are not always unique, but that at least some
elements of that knowledge or selected skills
may be relevant to the practice of other pro-
fessionals. Alternatively, especially when the
CME activity occurs in their practice com-
munity, physicians may conclude that a
shared continuing education experience with
other professionals might diminish their
standing as specialists.
Many physicians embrace the
notion that learning models
should reflect practice reality. If
the physician practices in an
interdependent manner with oth-
er professionals, learning activi-
ties logically should be structured
to be interdisciplinary. Several of
our well-attended conferences at
the University of Iowa are interdisciplinary
courses dealing with diverse health care con-
ditions such as arthritis, diabetes and AIDS.
The stature of the physician, as a member
and leader of the health care team, is not
only based upon the expertise of the physi-
cian, but also the understanding and respect
shown by that physician toward all profes-
sional colleagues. ^
Our abilities have
been enriched
through communi-
cation with other
health care
professsionals.
Richard Nelson, MD
Iowa Medicine Volume 85 / 10 October 1995 415
Iowa [Medicine
Classified Advertising
General Surgeon BE/BC
The Department of Surgery at the Mayo
Clinic, in conjunction with the Fairmont
Clinic, is seeking 2 broad-based general
surgeons to join a Mayo Regional Facility in
Fairmont, Minnesota, 120 miles west of
Rochester, Minnesota. This position offers
an excellent opportunity to establish a surgi-
cal practice in an established 15-person
Mayo-affdiated medical clinic in this town
of about 1 1 ,000 with a 77-bed hospital and a
service population of 45,000. This opportu-
nity allows practice autonomy, a wide spec-
trum of general surgery, including some
gynecological and orthopedic expertise and
excellent salary and benefits. Inquires:
Michael G. Sarr, MD
Department of Surgery
Mayo Clinic
Rochester, Minnesota 55905
Mayo Foundation is an affirmative action and
equal opportunity educator and employer.
No Assembly Lines Here — FPs, IMs and OB/
GYNs at North Memorial-owned and affiliated
clinics don’t hand patients off to the next
available specialist. Guide your patients
through their entire care process at one of our
25 practices in urban or semi-rural Minneapo-
lis locations. Plus, become eligible for 515,000
on start date. Interested BC/BE MDs, call 1/
800-275-4790 or fax CV to 612/520-1564.
Iowa, Nebraska
and Illinois
Seeking quality physicians inter-
ested in primary care and/or OB/
GYN locum tenen opportunities.
• Part-time and full-time
• Numerous Iowa, Nebraska and
Illinois locales
• Work as much or as little as you
desire. You pick the hours and the
location.
• Highly competitive compensation
• Paid St. Paul malpractice
Send CV or contact
■ i Melissa J. Milliken, CMSC
[A ACUTE CARE , INC.
* " PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: acute/urgent
care, family practice, oncology/hematology,
orthopedic surgery and general internal
medicine practice. The Mankato Clinic is a
70-doctor multispecialty group practice in
south central Minnesota with a trade area
population of +250,000. Guaranteed salary
first year, incentive thereafter with full range
of benefits and liberal time off. For more
information, call Roger Greenwald, Executive
Vice President, at 507/389-8500 or Byron C.
McGregor, Medical Director, at 507/389-8548
or write 1230 East Main Street, P.O. Box 8674,
Mankato, Minnesota 56002-8674.
Assistant Residency Director, Department of
Family Practice, University of Iowa College of
Medicine — The Department of Family Practice
at the University of Iowa College of Medicine is
seeking an ABFP-certified physician to join the
faculty as an Assistant Residency Director.
Responsibilities include curricular design,
procedural skills training and resident
recruitment. The successful candidate will
have practice experience and a minimum of
one year teaching experience at the residency
level and have competency in obstetrics. The
department has a well-established 24-resident
program that is university-administered,
community-based and has admissions at
community and university hospitals. The
program is actively supported by both
hospitals. A new model office facility is being
built and expansion beyond the present one
satellite rural office site is being pursued. As
part of the full academic department,
responsibilities include teaching, research and
patient care. Academic appointment can be in
either the traditional tenure track or a new
clinical track. Scholarly activity is expected
and supported. Appointment and salary
commensurate with qualifications and
experience. The University of Iowa is an
Equal Opportunity/Affirmative Action
Employer. Women and minorities are strongly
encouraged to apply. Submit a letter of
interest and CV to George R. Bergus, MD,
Residency Director, Department of Family
Practice, 2015 Steindler Building, Iowa City,
Iowa 52242; 319/335-8456.
Des Moines — IM, FP, PD needed to join
growing elite practice! Above average salaries,
good call coverage, excellent benefits. Call
Mary Latter at 800/520-2028! Job #M141MJ.
Marshalltown Medical
& Surgical Center
Seeking quality primary care
trained or emergency medicine
physician to practice at MMSC.
• Stellar EM practice
• Full-time, regular part-time and
moonlighting opportunities
• 14K annual volume
• 12-hour shifts, 24-hours/7day
coverage
• Excellent benefit/bonus packages
• Paid St. Paul malpractice
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE, INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Call me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Springfield, Missouri — Bass Pro Shop and 40
miles to Branson. BE/BC FPs. OB optional,
salaried position and production bonus, call
1:7, teaching hospital, university community.
Contact Vivian M. Luce, Cejka & Co., 1/800-
765-3055 or fax CV for immediate attention to
314/726-3009 (IMs welcome).
Escape from the ordinary! — General surgeon
needed to work in our thriving rural family
practice. Candidate should have skills in C-
section, gyne and laparoscopic surgery. Eight
weeks vacation/CME. Consultants available.
Only group in county with 3 referral centers one
hour away. Uniquely situated on 1-94 half way
between Madison and Twin Cities. Small town
pride, excellent 51-bed hospital, great schools
and recreation including all water sports, hunt-
ing, fishing, cross-country and downhill siding.
Cohesive group of caring physicians ! Contact or
send CV to Gary K. Petersen, Krohn Clinic, Ltd.,
610 W. Adams St., Black River Falls, Wisconsin
54615; 715/284-4311.
416 Iowa Medicine Volume 85 / 10 October 1995
CLASSIFIED ADVERTISING
Buena Vista
C3
J
a
o
55
County Hospital
Seeking quality primary care
trained or emergency medicine
physician to practice at BVCH.
•60-hour weekend shifts (6 pm
Friday to 6 am Monday)
• Approximately 45-55 patient
volume per shift
• Highly competitive compensa-
tion
• Paid St. Paul malpractice
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE , INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Ambulatory Care
Clinic
Seeking quality physician to prac-
tice either part, full-time or moon-
lighting during residency.
• Primary care, urgent care, oc-
cupational and sports medicine
• Weekday, weeknight and week-
end shifts
• Paid St. Paul malpractice
• Excellent benefit/bonus packages
Send CV or contact
1 Melissa J. Milliken, CMSC
j\ ACUTE CARE, INC.
• PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Family Practice Physician — Rare opportunity
for a BE/BC family practice physician to join
an established, progressive 8-physician
practice in Marshalltown, Iowa, a thriving
family oriented community 40 miles northeast
of Des Moines. We have a beautiful new
facility, a qualified staff and enjoy a supportive
relationship with our 176-bed local hospital.
Our philosophy is to provide personal, quality
care to each of our patients, while maintaining
our productivity, profitability and efficiency.
This position offers an excellent benefit
package, a voice in decision-making, 1 in 8 call
and a very7 competitive salary/dividend
package. For more information call or write to
Michael Miriovsky, MD or James Burke, MD,
Center for Family Medicine, PLC, 312 E. Main
Street, Marshalltown, Iowa 50158 or call 515/
752-5469.
s
Acute Care
GO
Anesthesia Services, LC
-03
s_
Recruiting MD/DO
Anesthesiologists & CRNAs
QJ
• Professionally rewarding,
Z
equitable anesthesia practices
• Full-time and part-time
• Incentive-based compensa-
m
tion and benefits — including
St. Paul medical professional
liability insurance
W
Send CV or contact
K. QDQDDDQD
HBQaanoQs
30300000
i Melissa J. Milliken, CMSC
HoaGaoDSB
™§QaooFriaG
J. an
[\ ACUTE CARE, INC.
^■SQaaaQEiio 1
MWooBnooau
■WjOnDQDODO
V
PO Box 515, Ankeny, LA 50021
800/729-7813 or 515/964-2772
MH
Fax 515/964-2777
STORM LAKE, IOWA
Rural lakeside community provides unique
setting for self-styled family practice. Em-
ployment with clinic foundation owned by
county hospital means no buy-ins, 1:9 call
coverage with weekend ER relief coverage,
full employment contract with guarantee
and excellent benefit package. You deter-
mine what patients to hand off in an outpa-
tient hospital based referral system of 25
specialists. A+ schools, A+ recreations and
A+ amenities. Send CV or call Darrell
Pritchard, Administrator, Buena Vista
Clinic, Box 742, Storm Lake, Iowa 50588;
collect 712/732-5012; fax 712/732-2538.
Internal Medicine and Family Practice Oppor-
tunities— Rural lake country community is seek-
ing the above practitioners to join an active 13-
physician multispecialty group. Quality, com-
fortable livingenvironment, multiple recreational
activities, fine educational opportunities and
cultural activities abound. Opportunity includes
relaxed call, liberal salary7 and exceptional ben-
efits. Send curriculum vitae or inquiries to Lake
Region Clinic, PC, Attn: Joel Rotvold, PO Box
1100, Devils Lake, North Dakota 58301 or call
800/648-8898 for further information.
Time For a Move?
BC/BE FP, IM, OB/GYN, PEDS
Our promise — Well save y7ou valuable time by
calling every7 hospital, group and ad in your
desired market. You’ll know every7 job within 7
day's. We track every7 community in the coun-
try, including 2000+ rural locations. Cedar
Rapids, Des Moines, Quad Cities, Kansas City,
Boston, Chicago, Indianapolis, many more.
New openings daily — call now for details!
The Curare Group, Inc.
M-F 9am-8pm, Sat 1-5 pm EST.
800/880-2028, Fax 812/331-0659
.lob #C133MJ
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for 82.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for 825 per
column inch, per month Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85 / 10 October 1995 417
Iowa [Medicine
CLASSIFIED ft D V E R T I S I N G
Director, Obstetrics and Gynecology —
Broadlawns Medical Center, a 200+ bed
county/community teaching hospital serving
metropolitan Des Moines and Polk County, is
seeking a well-rounded physician to direct the
ob/gyn department. Activities will include
supervising patient care teaching of family
practice residents, a rotating ob/gyn resident
and medical students in OB (500 births per
year and growing). Department includes
medical office clinical facilities, a Family
Birthing Center with LDRP room accommoda-
tions; a Family Planning Program and mid-wife
positions. Qualifications include an MD or DO
degree, board certification or active candidacy
of the American Board of Obstetrics and
Gynecology, extensive practice experience and
the ability to direct staff and programs to
support the service and education goals of the
facility. Clinical teaching experience is
desirable. Post offer/pre-employment physical
and drug screen required. This is a University
of Iowa clinical appointment. Take the
challenge and join our team! If interested
contact D.J. Walter, MD, 1801 Hickman Road,
Des Moines, Iowa 50314; 515/282-2203.
Minorities and women encouraged to apply.
Broadlawns is an Equal Opportunity/Affirma-
tive Action Employer.
Floyd Valley Hospital
Seeking quality primary care
trained or emergency medicine
physician to practice at FVH.
• 4300 average volume ER
• Medical director and staff posi-
tions
• Full-time, regularpart-timeand
moonlighting opportunities
• Weeknight, 12-hour shifts and
weekends
• Highly competitive salary
• Paid St. Paul malpractice
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE, INC.
f PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Vice President, Medical Affairs — Small regional
health system in medium-sized Midwestern com-
munity seeks an experienced medical executive.
Progressive managed care environment. Need a
visionary who is strategic and quality-focused
and has strong administrative/organizational
skills. Great opportunity. Gall or write Michael F.
Doodv, Witt/Kieffer, Ford, Iladelman & Lloyd,
2015 Spring Road, Suite 510, Oak Brook, Illinois
60521; 708/990-1370; fax 708/990-1382.
Family Physician — Family Medical Center is
actively recruiting a BE/BC family physician to
join 8 other family physicians and one general
surgeon. Practice opportunity provides 1:9 call
schedule, with full-time hospital ER coverage.
Con tract provides for attractive salary and excel-
lent benefits. Send CV to Linda Cohrt, Office
Manager, 1225 C Avenue East, Oskaloosa, Iowa
52577 or fax 515/672-2258.
^/hercy health center Emergency Medicine Opportunity
MASON CITY. IOWA
North Iowa Mercy Health Center (NIMHC), Mason City, Iowa, is a private, not-for-profit, 350-bed medical
center that services a 14+ county region in north central Iowa. For most of a century, NIMHC has combined the
most advanced technology with compassionate care to provide our region with quality medical services.
We are seeking a BC/BP primary care physician with emergency medicine experience or an emergency
trained physician for a full-time position in our facility. We invite you to become a part of our 4-member team in
a modern ED with 23,000 annual visits and weekend double coverage. This position offers competitive compen-
sation and an exceptional benefit package.
Mason City represents the best of the Midwest. It has quiet, tree-lined streets in modem neighborhoods and
radiates that storybook "hometown" feeling. An incomparable lifestyle can be derived from the matchless public
and parochial school system, a strong and growing economic base and the availability of ample recreational
activities.
We would welcome the chance to discuss how this opportunity can fulfill both your professional and
personal needs. For more information, please contact:
Laura Weis, Representative
North Iowa Mercy Health Center • c/o Mercy Health Services
4500 Westown Parkway, Suite 250 • West Des Moines, Iowa 50266
515/224-3260; 515/224-3546 (fax)
418 Iowa Medicine Volume 85 / 10 October 1995
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
Iowa [Medicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrey, Ml), PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology >
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Vcljko K. Zivkovich, MD
Robert A. Column, MD
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Robert J. Barn’, MI)
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery’ of Skin
Fort Dodge Medical Center, PC
Carey A. Rligard, MI), FAAD
James I). Bunker, MD, FAAD
800 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milncr-Bragc, Ml)
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
420 Iowa Medicine Volume 85/ 10
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gcrvich, MD
Daniel J. Schrocdcr, MD
Ravi K. Venturi, MI)
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Iotva Fertility, PC
Donald C. Voting, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
TVF and GIFT Procedures
Donor Oocyte Program
Artificial Insem inations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Art on I, MD, FICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard 11. Brandt, MD, ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MD
Laurence S. Rrain, MD
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Rat al, Ml), MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgcsc, MI)
Loren J. Mouw, MD
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
llosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
October 1995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Ilayne, MI)
Thomas A. Carlstrom, MI)
David J. Roariui, MI)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MI)
S. Randy Winston, MI)
Douglas R. Koontz, Ml)
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad I). Ahcrnathcy, Ml)
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, Ml)
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell 11. Watt, MD
John M. Graethcr, MD
Gilbert W. Harris, MD
James A. Davison, Ml)
Norman F. Woodlief, MI)
Erie W. Itligard, Ml)
David 1). Saggau, MD
Steven C. Johnson, MI)
Todd W. Gothard, MI)
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert I). Whincry, MI)
Stephen II. Wolkcn, MI)
Robert II. Goffstcin, MI)
Lyse S. Strnad, MD
John F. Stamlcr, MI), PhD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
Orthopaedic Surgery
l'ort Dodge Medical Center, PC
C. Mark Race, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
North Iowa Eve Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MD
Randall S. Brenton, MI)
James L. Dummett, MD
Mick E. Vandcn Bosch, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MI)
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MI)
Marshall C. Grcinian, MI)
Steven R. Herwig, DO
Thomas O. Paulson, MI)
Mark K. Zlab, MI)
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry’, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Ilill, MD
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Iowa Orthopaedic Center, PC
Marshall F'lapan, MD
Sincsio Misol, MD
Joshua 1). Kiniclman, DO
Timothy G. Kenney, MD
Lynn M. Lindaman, MD
Jeffrey M. Farher. MD
Kyle S. Gallcs, MD
Scott A. Meyer, MI)
Cassini M. Igruni, MD
Rodney FA Johnson, MI)
Martin S. Roscnfcld, DO
Teri S. Formanck, MI)
Stephen M. Naruto, MD
Donna J. Balds, Dll)
Jill R. Mcilahn, DO
Jacqueline iM. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery ’,
Facial Plastic Surgery, Allergy
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85 / 10 October 1995 421
Iowa Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MI)
Eugene Peterson, MD
Richard B. Merrick, Ml)
Peter V. Bocsen, MD
Robert II. Updegraff, MD
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neck
Surgery, PC
Thomas J. Benda, Sr., MD
James >V. White, MD
Craig C. Hcrther, MD
Thomas J. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MD
Guy E. McFarland, MD
Thomas F. Y'incr, MD
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Perinatology
I)es Moines Perinatal Center, PC
Neil T. Mandsagcr, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice I). Schncll, MD
Earccduddin Ahmed, MI)
Arthur B. Searle, MI)
Bogdan E. Krysztofiak, MD
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MD
Steven G. Berry, MD
Donald L. Burrows, MI)
Michael Witte, DO
Gerard A. Matysik, DO
Donald R. Shumate, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Surgery
Wendell Downing, MD
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Fort Dodge Medical Center, PC
Ralph E. Woodard, MD, FACS
Dan P. Warlick, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
i!
Robert G. Smits, MI), PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery \
Facial Plastic Surgery, Head
and Neck Surgery
Rehabilitation Medicine Associates
William 1). dcGravcIlcs, Jr., MD
Charles F. Dcnhart, MI)
Marvin M. Hurd, MD
William C. Koenig, Jr., MD
Karen Kicnker, MD
Todd C. Troll, MI)
Lori A. Sapp, MI)
Younker Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgesc, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology >, Psychiatry ’, Anesthesiology,
Rheumatology
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Advertising Index
Bemie Lowe & Associates 427
Blue Cross Blue Shield 41*
Central Systems, Inc 401
Clarkson College 40£
Franciscan Skemp Healthcare 417
IMS Services 39(
Medical Protective 38(
Mercy Hospital 40'
MMIC 42"
Medical Management Strategies ....39*
Monroe Clinic 41.
North Iowa Mercy Health Center ..4T
OccuSystems, Inc 39
U.S. Air Force 41
422 Iowa Medicine Volume 85 / 10 October 1995
Iowa I Medicine
THE PRESIDENT COMMENTS
PAGs are a reality
In an ideal society, political action com-
mittees would not be needed. Whether or
not you favor the PAC system, PACs are
a reality and serve a function. I believe they
enhance access to political candidates and
members of state legislatures and U.S. Con-
gress. PACs also provide groups and organi-
zations with a way to get their candidates
elected. If other groups with political inter-
ests fund a PAC, it seems to me that we must
also do so to be sure that our interests are
represented.
IMPAC, which represents Iowa physicians,
is a bipartisan organization. Local IMPAC
members assist in evaluating candidates
seeking support. Previous voting records and
demographics of a voting district are also
used in determining support. If a
legislator has not supported our
position at least part of the time it
is unlikely he or she will receive
financial support from IMPAC.
IMPAC has done very well in
supporting winning candidates. In
1992, 86 of the candidates sup-
ported by IMPAC won. In 1994,
IMPAC was involved in 114 state races; 105
of these candidates won — a success rate of
92%.
In 1992, IMPAC contributed 892,000 to
political campaigns. In the amount spent we
ranked third as an individual group behind
the Iowa State Education Association and
Tax Payers United. However, the trial
awyers and the Iowa State Bar Association
ranked fourth and seventh and their com-
bined expenditures were 861,000 greater
than IMPAC. In 1994, our contribution to
state candidates was 875,427, which dropped
us to a ranking of sixth in PAC spendings.
The trial lawyers jumped to fourth place
spending 878,000 and the Bar Association
ranked seventh contributing 874,500. As
you can see, Iowa lawyers gave candidates
for state office nearly twice the amount given
by organized medicine. This makes it diffi-
cult to pass meaningful tort reform.
A portion of IMPAC dues go to AMPAC.
AMPAC supported all four of our congres-
sional candidates, contributing over 830,000
directly and conducting polls for Dr. Greg
Ganske and Jim Lightfoot.
Membership and contribu-
tions may wax and wane: politics
never ceases. We are all aware of
the political revolution taking
place in Washington with the cur-
rent congress. Columnist David
Broder has referred to the current
congress as one of the most signif-
icant in 40 years. All of us who
contributed to IMPAC and supported candi-
dates in various other ways had something to
do with this. Our support of IMPAC must
continue and increase. ^
In 1994,
IMPAC was
involved in 114
state races;
105 of these
candidates won.
Iowa Medicine Volume 85/11
Joseph Hall, Ml)
November 1995 431
Iowa | Medicine
FEATURE ARTICLE
The right
to privacy
public’s
right
to know
Joseph Hall, MD
Dr. Hall is a radiologist
practicing in Des Moines.
He is president of the
Iowa Medical Society.
This article was written
in consultation with IMS
legal counsel.
Recent incidents have focused attention on
Board of Medical Examiners (BME) activities
in disciplining physicians. The key issue is
what information is public and what is
confidential during the investigation of
complaints and in disciplinary proceedings
by a licensing board against a professional
licensed by the state.
Maintaining a balance between the rights
of a licensee, the BME’s need to obtain
extensive, sometimes privileged information
and the public’s right to know is critical.
Unfortunately, that delicate balance may be
in jeopardy. In several cases, the statement
of charges issued by the BME — a public
document — has appeared to include
information from complaint and investigative
files. Complaint and investigative files and
information they contain are specifically
made confidential by law.
IMS concerned over “blurring” of lines
The IMS is increasingly concerned about
the blurring of the lines between information
which is specifically made confidential under
state law and that which is public. Since the
law’s drafting and enactment in 1977, the
IMS has supported the principle that the
statement of charges is public
when properly prepared.
When the statement of charges
is public, agencies of state
government are accountable.
Public accountability protects
patients and provides a means for
elected officials, the public and the
group being regulated to monitor the
activities of the regulators. The goal is to
ensure that state regulators correctly
implement the statutes.
This is the basis of the state’s open records
law and administrative procedures act.
However, state laws also recognize that in
order to maximize the flow of information to
licensing boards, limits on public disclosure
must exist. With regard to complaints
against licensed professionals, the statutory
limits are clear.
Disciplinary proceedings are considered
contested cases under the Administrative
Procedures Act, Chapter 17A, enacted in
1974. Since the notice of hearing in a
disciplinary proceeding under Section
17A.12 was not specifically made
confidential, it is a public record pursuant to
the state Public Records Eaw enacted in
1967, so long as the notice was limited to the
information required by Section 17A.12 and
did not include information made privileged
by Section 272C.6(4).
Section 17A.12 of the Iowa Code provides
that the statement of charges is to contain
only the following elements: the name of the
licensee, a reference to the statute or rules
alleged to be violated and a “short,
plain statement of the matters
asserted”. Chapter 272C.6(4)
limits what can appear in the
short, plain statement contained
in the notice by providing that
complaint and investigative
information is confidential. If
The statement of
charges is pubSic
but the information
if contains is
strictly limited.
432 Iowa Medicine Volume 85 111 November 1995
FEATURE ARTICLE
such confidential investigative information
finds its way into the statement of charges,
the statement is contaminated and its release
violates the law.
The IMS has long supported the carefully
crafted balance the law contains; the
statement of charges is public but the
information it contains is strictly limited.
IThe IMS believes current statutes are violated
when the BME files (and immediately releases
to the press) statements of charges which
contain investigative information, unproven
allega-tions and other unnecessary narrative
detail.
IMS position made clear in court
The IMS filed a petition of intervention and
a statement of position in the much
publicized case of John Doe II. These
reiterate the position that a statement of
charges which is contaminated with
confidential information cannot legally be
made public. The IMS does not assert that all
statements of charges are confidential.
IMS representatives were actively involved
in the legislative proceedings during the
passage of the 1977 bill regulating licensed
professionals. The purpose was to improve
professional discipline for the protection of
the public. The IMS supported the bill
The legislation provided for the the
maximum flow of information to licensing
boards. Licensees are required to report to
their respective boards negligent or careless
acts or omissions of others licensed by the
same board. Insurance companies are
required to report “incidents” involving
insured licensees which may constitute
negligent or careless acts or omissions. Other
persons are encouraged to report incidents.
Licensing boards were given the power to
require licensees to submit to physical or
mental examinations which could be used
against them. Sweeping powers were granted
to licensing boards to obtain professional
records “whether or not privileged or
confidential under law”.
As a result, the licensing board’s complaint
and investigation files contain information
which has universally been considered
privileged and confidential medical and
mental health information, especially patient
specific information and patient records.
The law balances the need to protect the
public through effective license discipline
against the public policy of protecting
medical and mental health information,
especially patient specific information and
patient records. This balancing is expressed
in Section 272C.6(4) by providing that the
BME’s complaint files, investigation files and
other investigation reports and information
are privileged and confidential and not
subject to discovery or subpoena.
The BME has not been granted the
authority to decide what information is
privileged and confidential in their complaint
and investigative files — it all is. Without this
protection, people would be reluctant to file
complaints and provide information, fellow
professionals would be reluctant to be
“informers” and patient records would not be
forthcoming.
The law also provides for accountability by
making public the final decision and findings
of fact in license discipline proceedings and
informal settlements. Each licensing board
must file an annual report to the legislature
including the number of complaints,
judgments and settlements investigated by
the board, the number of formal disciplinary
proceedings commenced by the board and
the number and types of sanctions imposed.
A careful balance
Effective license discipline requires the
provision of the maximum information
possible to the licensing boards while
maintaining the privileged and confidential
status of medical and mental health
information, especially patient specific
information. All in all, the law is a careful
balance of conflicting public policies to
achieve effective discipline. HZ3
The law is a careful
balance of
conflicting public
policies to achieve
effective license
discipline.
Iowa Medicine Volume 85 /II November 1995 433
Iowa I Medicine
IMS Update
CURRENT ISSUES
AT A GLANCE
In January, the IMS
continues its education-
al effort in the area of
violence prevention.
The January issue of
Iowa Medicine will be
devoted to elder abuse.
Experts will discuss
how to recognize elder
abuse, why elderly peo-
ple tolerate abuse and
physician reporting
responsibilities.
•
Jamal Hoballah, MD, a
surgeon in Iowa City,
has been appointed to
replace William Bonney,
MD as District II IMS
Councilor. Dr. Bonney
has retired.
♦
IMS dues statements
were mailed in mid-
October. Iowa is unified
at the state and county
levels. Prompt payment
of your dues will be
greatly appreciated.
Did you get your IMS Directory?
You should already have received your
new 1995-96 IMS Membership Directory. The
Directory contains a listing of IMS member
physicians, a physician referral section and
other pertinent information. If you have not
received your directory, please call Sheryal
Westbrook at the IMS, 515/223-1401 or
800/747-3070. Extra copies are available to
IMS members for $10.
Specialty" Society Update
A presentation by Medco of Iowa on the first six
months of managed mental health care for
Medicaid patients highlighted the Iowa Psychiatric
Society’s Annual Meeting in Iowa City October 27-
28. The IPS recently completed a survey of mem-
bers and their experiences with Medco; results
were shared with various governmental agencies
and the Governor’s office.
In recognition of Mental Illness Awareness Week,
the IPS and several other organizations sponsored
a conference on mental health insurance coverage
at the Des Moines Botanical Center October 6.
The Iowa Association of County Medical Examiners
Annual Meeting was held November 3 at the
Sheraton Inn, Cedar Rapids.
The Iowa Association of Pathologists recently
elected new officers for 1996-97: President —
John Van Rybroek, MD, Iowa City; Secretary-
Treasurer — Doryl Buck, MD, Cedar Rapids.
Roy Overton, II, MD, president of the American
Medical Directors Association, Iowa Chapter, was
appointed by the Governor as a delegate to the
recent White House Conference on Aging.
New officers for the Iowa Medical Group
Management Association are: President — Nancy
Park; President-elect — Steve Hilpiper; Secretary
— Denise Chaffee; Treasurer — David Lindner; Past
President — Alice Eveleth. New board members are:
Julie Barto, Joy Willis, David Weiss and Terry Stone.
For more information about any of the above
meetings, call Dana Petrowsky or Dave Fumeaux
at IMS Services, 515/223-2816 or 800/728-5398.
Schedule change for Iowa Medicine
As part of the IMS strategic plan, the IMS
Board of Trustees approved a reduction in
the number of issues of Iowa Medicine which
will be published each year.
The Journal, like other scientific publica-
tions across the country, has suffered from
the loss of pharmaceutical advertising and
skyrocketing paper costs.
Consequently, the Board voted to publish
Iowa Medicine nine times each year rather
than monthly. However, the Board stressed
that the format of Iowa Medicine will remain
the same.
Beginning in 1996, the following issues
will be combined — May/June, July/August
and November/December. A one-page news-
letter will be sent to all members in June,
August and December.
IMS video well-received in Des Moines
Representatives of the Des Moines busi-
ness community, the Iowa Legislature, law
enforcement and others attended the Des
Moines premier of the Iowa Medical Society
video “Break the Silence; Begin the Cure”.
Bonnie Campbell, director of the U.S.
Justice Department’s Violence Against
Women office, was the keynote speaker.
Ms. Campbell praised the Iowa Medical
Society and the American Medical
Association — in particular, past AMA
President Dr. Robert McAfee — for their
efforts in the area of family violence.
Also attending the Des Moines premier of
the IMS video were Iowa Lt. Governor Joy
Corning and Des Moines Police Chief William
Moulder.
All three Des Moines television stations
and WHO-radio did stories on the IMS video
and the domestic violence education pro-
gram. EJ
434 Iowa Medicine Volume 85/11 November 1 995
Who?
Tou.
Sky Plus® Travel Club is introducing
a special program exclusively for IMS
Association Members and their families
What?
With the IMS/Sky Plus® Travel Club,
you save every time you travel. ..on air
fares, hotels, car rentals, and more.
Or phone 1-800-723-8686
AND ASK FOR THE ASSOCIATION DESK
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This offer is only valid until 12/15/95.
Call today:
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Iowa [Medicine
Futures
AT A GLANCE
A recent article in USA
Today says the GOP
plan to turn Medicaid
over to the states faces
three major stumbling
blocks. The president
will oppose it; interest
groups will lobby hard
against it and states
that stand to see fund-
ing drops under the
new plan will pressure
their lawmakers to
oppose it.
•
A recent study found
that babies delivered by
C-section and dis-
charged within 24
hours of delivery are
3.3 times more likely to
get sick enough for
readmittance than if
they stayed two or more
days. The study also
found that 58% of moth-
ers with HMO coverage
were discharged within
24 hours or less of
delivery while only 36%
of non- HMO mothers
were discharged within
24 hours.
IMS continues meetings with Medco
Representatives of the Iowa Medical
Society and the Iowa Psychiatric Society
(IPS) continue meeting with officials of
Medco Behavioral Care (MBC), the
Department of Human Services and the
Governor’s office regarding concerns about
managed mental health care for Iowa’s
Medicaid population.
The September Iowa Medicine contained
a story which examined the first six months
of operations by MBC, the company under
contract with the state to manage mental
health services for Title 19 patients.
The Iowa Medicine story outlined a num-
ber of concerns about MBC operations
expressed by physicians, juvenile judges,
legal services and other advocates for chil-
dren. In the story, officials of Medco and the
Department of Human Services (DIIS) said
Medco is working to correct problems.
The Des Moines Register also examined
the issue in a lengthy story in its Sunday,
September 18 edition. This story and a sub-
sequent editorial explored the question of
whether patients — especially children — are
suffering because of Medco’s policies.
In an attempt to work out problems, IMS
and IPS staff have held frequent meetings
with Medco representatives.
Late this summer, the IPS surveyed its
members regarding Medco’s policies and per-
formance. Results of this survey were shared
with the DHS, Medco staff and the Governor’s
office. A second survey is underway now.
Key issues discussed at the meetings
include difficulty in certifying needed patient
care, cumbersome processes, inappropriate
claim denials and delays in claims payment.
In addition to special meetings, IMS and
IPS staff also participate in a regular Provider
Round Table hosted by Medco.
For more information about Medco
claims payment, see story on page 440, the
Medical Economics section.
Medicare debate laughable, tragic’
A recent editorial in the Chicago Sun-
Times says the debate over the fate of
Medicare has reached proportions which are
“at once laughable and tragic”. Those on both
sides of the debate are being criticized for
inundating the public with contradictory,
inflammatory and mostly self-serving claims.
Meanwhile, James Todd, MD, executive
vice president of the AMA, said the AMA’s ini-
tial reaction to the Republican Medicare
reform plan is “basically favorable”. In par-
ticular, Dr. Todd cited a reduction in govern-
ment regulation over laboratories and
antitrust proposals.
Ethical implications of managed care
A coalition of New Jersey consumer groups
is asking the state’s Board of Medical
Examiners to investigate the legal and ethical
implications of managed care contracts that
reward physicians for containing costs.
The group is also concerned about plans
requiring physicians to sign agreements that
bar them from discussing the organization’s
utilization review procedures. EH]
IMS Services offers managed
CARE NEWSLETTER
IMS members can get the independent
newsletter Physician Network Insider at a
significant discount. The newsletter is pub-
lished by United Communications Group
(UCG) which also publishes Part B News.
The Physician Network Insider provides
unbiased inside advice which can help physi-
cians and their practice managers survive
and prosper under managed care.
For more information, call UCG at
800/929-4824, ext. 223. (Mention the IMS.)
You will receive a subscription form in the
mail in the near future.
436 Iowa Medicine Volume 85/11 November 1 995
CURRENT ISSUES
C H M I $ Update
As part of the Iowa Medical Society’s ongoing effort to educate Iowa physicians about the
Community Health Management Information System (CHMIS), this CHMIS Update page is a regu-
lar feature in Iowa Medicine.
Progress toward the July, 1 996 implemen-
tation of Iowa’s CHMIS continues. Following
is a compilation of recent actions of the IMS
CHMIS Committee, the CHMIS Governing
Board and several subgroups appointed by
the Governing Board.
The Community Health Management
Information System (CHMIS) Governing
Board met September 15, 1995. The most
important issue was approval of the
Request for Proposal (RFP) for the data
repository. The data repository will be the
secure and confidential storage receptacle
for storage of data collected by CHMIS.
Organizations interested in bidding on
the data repository had until September 28
to send letters of intent and are to submit
bids by November 15. The Governing Board
will select a vendor by December 15, 1995.
IMS will not bid on CIIMIS repository
The IMS Committee on CHMIS had rec-
ommended IMS staff seriously explore
making a bid on the data repository; this
was supported by the Board of Trustees.
Since the IMS would not be able to under-
take this project alone, staff met with the
Association of Iowa Hospitals and Health
Systems and a neutral third party experi-
enced in electronic data transfers as
potential partners to submit a viable bid.
However, after reviewing the RFP and
deliberating about how the IMS could best
advocate for physicians in the CIIMIS
process, it was decided not to submit a bid
for the CHMIS data repository.
Primary concerns were the lack of time
to develop software and test the system by
July, 1996, an uncertainty about generat-
ing revenue to fund the repository and a
requirement that the data repository ven-
dor cannot have a vested interest in the
outcome of the data. This last requirement
seemed to effectively eliminate the IMS
and its potential partners from the bidding.
No certified CHMIS networks yet
The Governing Board approved the first
steps networks must take to become certi-
fied. Networks must first become accredit-
ed by the Electronic Healthcare Network
Accreditation Commission (EIINAC), an
organization committed to developing net-
work standards across the U.S. Once net-
works become accredited, they must meet
additional criteria which will be published
in the Iowa Administrative Rules.
Keep in mind there are no certified
CHMIS networks at this time. There prob-
ably will not be certified networks until
close to the July 1, 1996 implementation
date. There are software companies and
potential networks traveling Iowa using
CHMIS as a selling tool. Physicians should
be very cautious about any firm claiming
to be a certified network at this time.
What should physicians do?
The CHMIS Governing Board has made
it clear that physicians who face a burden
complying with the law will not be penal-
ized on July 1, 1996 if they have a plan and
are working to meet CHMIS requirements.
With this in mind, IMS staff recommend
physicians wait until more decisions are
made about CHMIS before expending
funds to meet CHMIS requirements.
The best strategy is to stay informed
about CHMIS developments and formulate
a strategy to comply with the law. Do not
panic and buy computer equipment and
software because of a sales presentation.
Watch for more guidance in future issues of
Iowa Medicine.
The IMS Board of Trustees met recently with
representatives of the CHMIS Executive
Committee. Watch next month ’s Iowa Medicine
for a report.
M
\ » /
on your horizon July 1, 1996
YOUR representatives
on state CHMIS
committees:
CHSV15S
Governing Board:
Dale Andringa, MD
Des Moines
515/241-4102
Beth Bruening, MD
Sioux Citv
712/233-1529
CHSVSBS advisory
committees:
Communications/
Education
Laine Dvorak, MD
Clarence Denser, Jr., MD
Data Advisory
John Brinkman, MD
Ethics/Confidentiality
Charles Jons, MD
Quality Review
Elie Saikaly, MD
William Langley, MD
Technical Advisory
Mark Purtle, MD
IMS CHMIS
Committee:
Terrence Briggs, MD (chair)
IMS staff:
Ed Whitver
Barb Heck
Dean Gillaspey
Iowa Medicine Volume 85 /II November 1995 437
Iowa [Medicine
Legislative Affairs
AT A GLANCE
In testimony before the
Senate Labor and
Human Resources Com-
mittee, AM A Trustee
Palma Formica, MD,
voiced strong AM A sup-
port for S. 969, which
would provide mothers
and babies with appro-
priate hospital coverage
following delivery. The
AMA believes physicians
and patients should
make discharge deci-
sions without outside
interference, said Dr.
Formica. So far, 10
states have enacted leg-
islation to protect moth-
ers and newborns.
•
Murder charges against
Jack Kevorkian, MD
have been dropped, but
the retired pathologist
faces charges of assisted
suicide in the 1991
deaths of two women,
the second and third of
25 he has attended. The
AMA publicly deplored
the decision to drop the
charges.
More on PA rules
An agreement has been reached between
the Board of Medical Examiners and the
Board of PA Examiners on several issues
relating to physician assistant supervision.
The joint rules review group composed of
representatives of the two boards have agreed
to continue the current requirement that a
PA have one year of experience before prac-
ticing at a remote site where the physician is
not always present.
The BPAE may reduce the requirement to
six months through a waiver process if the
supervising physician and PA have worked
together at the same location for at least
three months and the supervising physician
reviews and signs charts documenting the
PA’s patient care at least weekly for the first
year of practice at the remote site.
The current requirement of weekly visits
by the supervising physician to a remote site
has been reduced to every two weeks for PAs
with more than one year of practice experi-
ence. Exceptions may be made for emer-
gency circumstances.
Drug Therapy Management by Pharmacists
A new draft of rules has been issued by the
Board of Pharmacy Examiners relating to
drug therapy management by pharmacists.
The new draft would replace those that were
published for comment in June.
Several changes have been made to
attempt to address IMS concerns about the
rules; however, preliminary comments from
members of the IMS Committee on Legis-
lation indicate that the changes are not suffi-
cient to receive IMS support. The IMS will
share specific concerns with the Board of
Pharmacy Examiners.
Contact Lens Prescriptions
The Board of Optometry Examiners has
published rules for comment relating to the
release of prescriptions for contact lenses and
spectacle lenses. The initial draft of the rules
attempted to regulate ophthalmologists as
well as optometrists.
Both the IMS and the Iowa Academy of
Ophthalmology have sent comments request-
ing that the references to prescriptions by
MDs and DOs be removed because the Board
of Optometry Examiners has no authority
over physicians.
BME Rules for Surgical Care
The Board of Medical Examiners has pub-
lished rules for comment establishing stan-
dards of practice for preoperative, operative
and postoperative patient care.
The rules provide that the surgeon of
record in an operative case is responsible for
rendering an appropriate preoperative diag-
nosis, selecting the operation to be per-
formed in consultation with the patient,
determining the patient’s fitness for the oper-
ation, assuring that informed consent is
obtained and managing the patient’s postop-
erative care.
Legislative videotape available
A videotape presentation is available to
Iowa physicians who want information on the
Iowa Medical Society’s priorities for the 1996
Iowa Legislature. The tape is about 20 min-
utes long. On the video, physicians involved
in the IMS legislative program discuss the
IMS priorities and the impact of grass roots
involvement in the political process.
As scheduling permits, Paul Bishop, IMS
legislative liaison, will be on hand to answer
questions after the tape is shown. The video
would make a good program for county med-
ical societies or specialty societies.
Copies of the tape are available for loan to
IMS members. To borrow a tape or to arrange
for a legislative briefing in your area, call
Paul Bishop at the IMS, 515/223-1401 or
800/747-3070.
438 Iowa Medicine Volume 85/11 November 1 995
CURRENT ISSUES
Postoperative care management includes
delegating care to another qualified physi-
cian or delegating defined aspects of such
care to an appropriately trained nonphysi-
cian practitioner. Fee splitting or giving or
receiving fees in return for delegating postop
care is prohibited. These rules codify a pre-
viously issued declaratory ruling.
For copies of any of these rules, call
Becky Roorda at the IMS, 515/223-1401 or
800/747-3070, extension 618. El
Coming next month . . .
Is your pension safe in the event you are
sued? Read the December Iowa Medicine
Legislative Affairs section for a legal opinion
on pensions and Iowa law.
Occupational Medicine
Des Moines, Iowa
(Career Practice Opportunity)
OccuSystems, Inc. is the largest national occupational health care
practice management company in the U.S. today. We are currently
seeking a primary care physician for our occupational health center
in Des Moines, Iowa.
Occupational medicine experience is desirable but not required . We
offer regular work hours with a limited rotating call. In addition, we
guarantee an excellent starting salary along with a year-end bonus
program. Plus progressive future growth and a comprehensive corpo-
rate fringe benefit program . The chosen candidate will assist in the
development of the Des Moines, Iowa market.
If you are interested or would like additional information on this or
other opportunities, call Jeff Moffett, C.M.S.R. or Matt Mear at 1-800-
345-9958 or send your CV to:
Recruiting Dept.
OccuSystems, Inc.
3010 LB) Freeway, Suite 400
Dallas, Texas 75234
OccuSystems, Inc.
Innovative solutions
for occupational healthcare
OccuSystems, Inc. is an equal opportunity employer.
^/mei^y health center Emergency Medicine Opportunity
MASON CITY. IOWA
North Iowa Mercy Health Center (NIMHC), Mason City, Iowa, is a private, not-for-profit, 350-bed medical
center that services a 14+ county region in north central Iowa. For most of a century, NIMHC has combined the
most advanced technology with compassionate care to provide our region with quality medical services.
We are seeking a BC/BP primary care physician with emergency medicine experience or an emergency
trained physician for a full-time position in our facility. We invite you to become a part of our 4-member team in
a modern ED with 23,000 annual visits and weekend double coverage. This position offers competitive compen-
sation and an exceptional benefit package.
Mason City represents the best of the Midwest. It has quiet, tree-lined streets in modem neighborhoods and
radiates that storybook "hometown" feeling. An incomparable lifestyle can be derived from the matchless public
and parochial school system, a strong and growing economic base and the availability of ample recreational
activities.
We would welcome the chance to discuss how this opportunity can fulfill both your professional and
personal needs. For more information, please contact:
Laura Weis, Representative
North Iowa Mercy Health Center • c/o Mercy Health Services
4500 Westown Parkway, Suite 250 • West Des Moines, Iowa 50266
515/224-3260; 515/224-3546 (fax)
Iowa Medicine Volume 85 /II November 1995 439
Iowa [Medicine
Medical Economics
CURRENT ISSUES
Medco pays previously denied claims
AT A GLANCE
As House and Senate
Medicare platis were
unveiled, physicians
were pleased that cries
for regulatory relief had
been heard. The House
Ways and Means pack-
age exempts office labs
from CLIA and modi-
fieds self-referral bans.
Both packages add pro-
grams to fight fraud and
abuse and both give
medicine some long-
desired concessions.
•
In the first antitrust
lawsuits of their kind,
the Justice Department
charged yesterday that
hospitals with local
monopolies in Danbury,
Conn. and St. Joseph,
Mo., had joined with
doctors in illegal price-
fixing schemes to keep
out lower-cost managed
care companies.
Medco Behavioral Care (MBC), the man-
aged care company under contract with the
state to provide mental health services to
Medicaid patients, has notified providers of
several “claim action plans”.
According to a recent communication from
MBC to Iowa Psychiatric Society members,
MBC will address “both retrospective and
prospective claim improvements by address-
ing specific claim processing issues.”
First, MBC plans to pay “all claims which
have been denied due to a lack of precertifi-
cation”. According to MBC, about 12% of all
billed charges were denied due to lack of pre-
certification. Staff and provider training and
education issues may have created unneces-
sary denials, said the Medco letter.
MBC also planned to pay claims received
by November 1, 1995 for dates of service
before August 31, 1995 which were not pre-
certified.
In addition, eligibility for the Mental
Health Access Plan (MHAP) is now being
granted on a prospective basis only. Specifi-
cally, if a Medicaid client becomes eligible for
Medicaid benefits in one month, the client’s
eligibility for MHAP will begin the first of the
next month.
With this change and several training ini-
tiatives, the number of claims denied due to a
lack of precertification should be consider-
ably reduced, said MBC.
Medicaid debate heats up, too
Regions around the U.S. are fighting over
the way Medicaid dollars would be distributed
in new plans that have been proposed, such
as block grants.
Governor Christine Todd Whitman of New
Jersey, a Republican, and eight Republican
House members from New Jersey complained
that the Republican Medicaid bill would
shortchange their state, shifting money away
from the Northeast to the South and the West.
Representative Michael Forbes, a New York
Republican who calls himself a “loyal lieu-
tenant" in Newt Gingrich’s campaign to
reduce the role of the federal government,
says the Republican’s proposed Medicaid for-
mula is “absolutely unacceptable”.
The proposal would force some hospitals
on Long Island to shut specialized burn units
and cardiac care units.
Marshfield verdict overturned
A federal appeals court has overturned a
jury verdict that the Marshfield Clinic had
created an illegal monopoly that kept Blue
Cross and Blue Shield out of some parts of
Wisconsin. However, the Court of Appeals
upheld the jury’s finding that the clinic had
conspired with competitors to divide mar-
kets. The court ordered a retrial on damages
due to Blue Cross; Marshfield appealed.
An amicus brief supporting Marshfield was
filed by the AMA, the Medical Group
Management Association and the Wisconsin
Medical Society. HI]
440 Iowa Medicine Volume 85 /II November 1995
Iowa | Medicine
CURRENT ISSUES
Practice Management
Data collection pilot project
Physician-specific data is being collected
by insurance companies, the Iowa Health
Data Commission and the Iowa Department
of Public Health. This data will be part of the
Community Health Management Information
System (CHMIS).
The data is and will be used for many pur-
poses — to include or exclude physicians in
health care plans, to identify effective and
efficient providers in treatment of certain
diagnosis and to research practice variations
in different areas of the state.
Many experts believe that physicians must
take the lead in data collection, research,
interpretation and dissemination. The IMS is
attempting to determine member needs in
data advocacy and technology and how the
IMS can be of assistance to physicians.
For example, the IMS could provide addi-
tional insight into how data can be obtained,
whether the data is valid, what studies are
most beneficial to physicians and how the
data can be used to counter information used
by third parties.
The IMS is initiating a pilot project to
determine member needs in the area of data.
There will be a fee for participation. The pro-
ject will involve development of practice spe-
cific reports and physician specific profiles
for comparison to a confidential peer group.
Anyone interested in participating should
call Ed Whitver at the IMS, 800/747-3070.
GLIA questions answered by fax
Brief but comprehensive information on
commonly asked questions about CLIA regu-
lations is now immediately available free to
physicians and their staff. The same-day fax
service is available by calling COLA
Customer Service toll-free at 800/298-8044.
CLIA fact sheets will be faxed the same day
to any physician or laboratory inquiring
about a number of office laboratory-related
topics. The fact sheets condense information
from a variety of sources into a user-friend-
ly, one-page and two-page format.
There are 33 fact sheets covering topics
including: how to properly register your
shared laboratory with IICFA; requirements
for microscopy procedures performed by
providers; how to change your CLIA certifi-
cate; what to expect during a CLIA inspec-
tion; writing a procedural manual; and what
labs should know about documentation. IE3
Midwest Medical Insurance Company
Focus on Risk Management
Is your clinic prepared for an emergency?
Whenever your clinic is open for patient
treatment, your staff should be able to
respond to a patient emergency. The type of
emergency equipment, the level of staff train-
ing and the necessary emergency protocols
are determined by your specialty, the type of
procedures performed in the clinic and the
foreseeable emergencies that may arise.
Ensure that your clinic is prepared to handle
emergencies by implementing protocols:
•Assess the emergency equipment and
supply needs of your clinic. Oxygen, drugs
and equipment should be available according
to the procedures performed in your office.
•Inspect equipment routinely for func-
tioning and schedule routine maintenance
checks. Check drugs for expiration dates.
•Train staff in emergency response proce-
dures and conduct periodic in-services to
make sure all staff are aware of their roles
and responsibilities.
•Determine appropriate limits on the
types of patient contact that will be allowed
without a physician present. Assess the risk
of patient injury if the clinic allows non-
physician staff to render routine treatment
when there is no physician on the premises.
For further information, contact Lori
Atkinson, MMIC risk management supervisor,
MMIC West Des Moines office, PO Box 65790,
West Des Moines. Iowa 50265. 800/798-9870 or
515/223-1482.
AT A GLANCE
HCFA’s 1996 payment
rates for Medicare
HMOs for the 100 coun-
ties with the highest
enrollment in risk-
based managed care
plans range from
S3 13. 50 to S760.66 a
month. “The 1996 rates
demonstrate that Medi-
care payment rates for
managed care plans are
moving in parallel with
private sector pay-
ments, ” said Bruce
Vladeck, HCFA adminis-
trator. As of July 1,
about 2.8 million Med-
icare patients were en-
rolled in 167 risk-based
managed care plans.
There are no Medicare
HMOs in Iowa, but pro-
jected rates would
range from S200 to S400
per enrollee per month.
•
Most physicians have
cut back or eliminated
in-office lab testing
since CLIA went into
effect, a new study
finds. The study comes
on the heels of a federal
study claiming CLIA
has not adversely affect-
ed access to lab ser-
vices.
Iowa Medicine Volume 85 /II November 1995 441
Iowa [Medicine
Newsmakers
CURRENT ISSUES
AT A GLANCE
The Iowa Hopsital Asso-
ciation has changed its
name to the Association
of Iowa Hospitals and
Health Systems (IH &
HS). Officials stated the
change reflects the IH &
HS mission to represent
both hospitals and inte-
grated health systems.
•
HOPE, Health Occupa-
tions Partnership in Edu-
cation, a formal associa-
tion between Dubuque’s
Finley Hospital, Mercy
Health Center and North-
east Iowa Community
College (NICC), was
signed into agreement in
early August. This agree-
ment marks a coopera-
tive effort to provide con-
tinuing education oppor-
tunities for health care
professionals in the tri-
state area.
Another physician on the front line in WWII
Dear Editor:
Here is a story rarely heard about what
happened to soldiers captured by the Germans
in the Battle of the Bulge. In retrospect, the
government made two boo-boos: ( 1 ) They took
all the galoshes issued to the troops before
coming to France; (2) They immunized the
soldiers to every con-
ceivable disease ex-
cept diphtheria!
Soldiers in the
Bulge stood in icy wa-
ter for 36 plus hours.
Their feet were frozen.
Those unfortunate
enough to be captured
by the Germans were taken east of the Rhine,
marched 40 miles up and 40 miles down the
Rhine in the snow, before they were interned in
a prison camp called Limburg. There they stayed
for a month or so, together with some Russian
prisoners. The Russian prisoners were fed fairly
well and made to work. Our soldiers were
treated with psychological measures such as
starvation (with soup made of grass and other
greens). They were kept in a basement com-
pound. Once a day they would be given tiny bits
of G rations from the Red Gross. Tiny pieces of
chocolate or cheese or cookies. Afterwards the
soldiers would reminisce about wonderful food
they had at home. They knew that if they were
sick they would get better food, so many of
them laid next to a buddy with diphtheria, just
to catch the disease and become ill.
At the end of their imprisonment they were
skin and bones (like those at Auschwitz), lousy,
with black feet from frostbite. Many died of
starvation and other diseases. Many with diph-
theria had complications I had never seen.
Those who survived were transported to our
General Hospital, GH #182, in the English
Midlands. We cared for about 100 of those
unfortunates. We fed their cachectic bodies
slowly to avoid further complications, deloused
Letter
to the
Editor
them, shaved them and treated multiple dis-
eases prevalent as carry overs. I had seen dia-
betic gangrenous feet before and expected those
black feet to be amputated, but to my surprise
all of them got better without amputation! All
survived except a few with severe hepatitis or
pancreatitis.
I will never forget what tortures the so-called
master race could conjure up. The aggressive-
ness is immediately under the surface in all of
us. — Dr. Dan Glomset, Des Moines
Note: This letter was inspired by an article
in the August issue entitled “ Physicians on
the Front Line". If you have a story to tell,
send it to us; we'd like to hear from you.
Awards, appointments, etc.
Dr. Bery Engebretsen, director of Broadlawns
Medical Center’s Ambulatory Care Services in
Des Moines, was recently honored with two
prestigious national awards. The National As-
sociation of Community Health Centers pre-
sented him with the Samuel U. Rodgers Achieve-
ment Award for his outstanding contributions
to the health center movement. Dr. Engebretsen
was also presented with the Award for Excel-
lence by the National Health Service Corps for
his role in teaching and working with medical
students. Three longtime Dubuque physicians
recently retired from medical practice: Dr.
Tom Benda, Sr., otolaryngologist; Dr. Fred
Fuerste, ophthalmologist and Dr. Denis Faber,
urologist. Dr. William Erkonen, UI Hospitals
and Clinics, Iowa City, has been named a fellow
of the American College of Radiology. Dr.
Michael Chapman, orthopedics has joined Medi-
cal Associates in Dubuque. Dr. R.C. Wooters,
Des Moines, has retired after more than 30
years of service as Polk County Medical Exam-
iner.
I
Deceased member
John Baker, MD, 67, general practice, Ma-
son City, died May 24 UuJ
442 Iowa Medicine Volume 85/11 November 1 9 95
Iowa I Medicine
FEATURE ARTICLE
£ & M coding . . .
Is Iowa complying with
HCFA guidelines?
‘Educate, not intimidate’
John Olds, MD
The American Medical Association
ji introduced the new evaluation and
management (E & M) codes in 1992. At that
time, there was agreement that the Health
i Care Financing Administration (IICFA)
would allow physicians an opportunity to
I become familiar with the codes before being
subjected to Medicare audits.
In late 1994, the AMA and the HCFA
jointly published E&M documentation
guidelines. HCFA developed a documen-
tation “score sheet” to be used by all
carriers. In addition, HCFA instructed
Medicare carriers to:
• Introduce the guidelines over six months
(November 1994-April 1995);
• Implement educational monitoring over
1 three months (May-July 1995); and
• Begin to audit and downcode E&M
services as appropriate with dates of service
August 1, 1995 or after.
As the carrier medical director, I am
responsible for implementing the E&M
documentation guidelines in Iowa.
Physicians have become increasingly
anxious about Medicare’s scrutiny of their
documentation. While audits are a necessary
process for all tax-sponsored
programs, now is the time to
educate, not intimidate. This is the
reason considerable effort went
into the educational monitoring
process.
We conducted an educational
Iowa audit for the monitoring
period May-July, 1995. We
randomly selected 150 E&M visits.
Each physician selected was asked to
volunteer for an educational audit by
submitting documentation for one E&M
encounter.
In return, each physician was given the
result of the documentation review,
including the score sheet as completed by
Medicare staff.
Though our sampling cannot be
considered scientifically valid, some trends
did emerge.
Inadequate attention to system review
Foremost was the lack of documentation
of a review of systems as part of the patient’s
history. System review components could be
found scattered in the record — usually in
the history of present illness, sometimes as a
separate review of systems entity and
occasionally in the examination or
assessment.
However, inadequate attention to
recording system review too often led to a
low level E&M encounter which otherwise
would have supported a higher level code.
Specifically, if no system review is
performed, only the lowest level of history is
justified.
The second documentation problem was
found in the history of present illness. The
category presenting many of the
difficulties was the ‘patient with a
stable chronic condition’ (i.e. ,
hypertension or diabetes).
Often, the only history of
present illness was “patient in for
a recheck.” This not only fails to
describe the history of the
continued
“Though ©isr
sampling cannot
lie considered
scientifically valid,
some trends did
emerge”
John Olds, MD
Dr. Olds , a Des Moines
internist, is co-chair of
the Medicare Carrier
Advisory Committee and
medical director for
Medicare in Iowa.
Iowa Medicine Volume 85 111 November 1995 443
Iowa | Medicine
FEATURE ARTICLE
continued
Kent Moss, MD
Dr. Moss, an Algona
family physician and
member of the Mercy
Family Care Network, is
co-chair of the Medicare
Ca rrier Advisory
Committee.
present illness, but also leaves the reviewer
guessing about what that illness might be.
Problems with exam component
Our monitoring results also show that
physicians in subspecialities appeared to have
more coding/documentation problems than
family physicians and general internists.
Much of this difference can be attributed to
the exam component.
The only exam criteria available from
IICFA at this time includes all body
systems/areas and these are tailored to the
presenting problem and physician specialty.
Carriers are anticipating single system exam
criteria from the national specialty societies
and IICFA. If and when these become
available, Medicare will publish the criteria.
Medical decision-making
Our chart reviews indicated that
documentation of the physician’s decision-
making process was adequate to support the
billed code. This is generally because
decision-making flows from the findings on
history and examination.
That is, the number of diagnoses or
management options, the amount and
complexity of data and the overall risk — the
determinants of decision-making — depend
upon the patient’s presenting problem, which
is characterized by the history and exam.
Summary
In addition to my responsibilities as the
carrier medical director, 1 am a practicing
physician. I recently documented con-
sultations on two cases and decided to score
my documentation using the IICFA
guidelines.
What I found was my “gut reaction” code
selection was not supported by my
documentation. In both cases, I had
overcoded by one level of service. Like the
E&M records I had been reviewing in my role
as carrier medical director, I was lacking in a
documented history and found the exam
criteria restrictive for my specialty.
I encourage physicians to score their own
documentation. This little scoring exercise
took less than 30 minutes, but it made me
aware of the scoring criteria as it applies to
my specialty and identified where I need to
concentrate my documentation efforts.
Kent Moss, MD
Physicians can find out how well they are
doing on E&M coding by implementing an
ongoing monitoring system. We have done
this in our office and each physician receives
useful information about their own coding
choices and substantiating documentation.
The program has been in place over four
years, since 1992 when the new E&M coding
system was implemented. Originally we used
an outside firm, Partners Consulting Group,
to help us establish our program, but now it
is maintained by our reimbursement and
coding staff as part of their job respon-
sibilities.
There are three parts to our system:
• monthly statistical profiles
• medical chart assessment
• follow-up action, as needed
Monthly profiles
Each month every physician in our
network receives his or her own code profile
and worksheet. The profile shows a rolling
three-month graph of the physician’s
utilization of the established patient office
visit codes compared to peer group norms.
Review of the monthly graph is helpful foi
444 Iowa Medicine Volume 85/11 November 1 995
FEATURE ARTICLE
99211 99212 99213 99214 99215
100
Code profile
99211 99212 99213 99214 99215
Graph A
Graph B
identifying questions, trends and areas for
; action. Appropriate coding and changes in
coding choices are also evident from the
graphs.
Examples of individual profiles are shown
in Graphs A & B. The physician profiled in
Graph A shows a higher utilization of code
99212 than the peer group and may warrant
additional review. The physician profiled in
Graph B shows a trend toward decreasing
use of code 99212, although still significantly
above the peer group.
;
Chart assessment
Although we are currently doing actual
chart assessments only twice per year for
each physician, our goal is to provide the
feedback quarterly. The chart assessment is
done by our reimbursement coordinator. She
compares the physician’s documentation to
!the HCFA documentation guidelines and
then determines if the billed code is
(substantiated. She uses various methods to
select the chart samples, but averages 10-15
charts for each provider’s assessment report.
She uses the same “score sheet” the Iowa
Medicare carrier uses to review docu-
mentation and feels it is consistent, accurate
and works well for our monitoring.
The chart assessment report is compiled
for the whole clinic, but each physician also
gets his or her own results. Our reim-
bursement coordinator attends one of our
regular monthly meetings to present the
clinic report and identify areas for action.
Follow-up action
Education is our most common follow-up
action so far. We have conducted on-site
sessions at our clinics to review coding
guidelines and documentation requirements.
The most effective sessions are when our
physicians actually do chart assessment on
their own documentation and “score” their
own work. We find a physician can do one
chart in about 10-15 minutes including
discussion of the findings.
Don’t be afraid to ask for help
Physicians need to pay attention to coding
and documentation and we find an ongoing
monitoring system helps them do that. The
monthly profile graphs influence coding
choices and chart assessments confirm good
record documentation or highlight weak-
nesses in time to make improvements.
I encourage every physician to pay
attention to their coding and documentation
and seek help, if needed. Currently our
system is not tied to compensation or
incentives, but it could be in the future. And,
if we are audited by HCFA, we have had a
chance to analyze our coding and docu-
mentation practices before IIGFA does. EH
For assistance or
more information
on HCFA’s
guidelines for
E & M coding, call
Barb Heck at the
IMS, 515/223-1401
or 800/747-3070.
Iowa Medicine Volume 85 / 11 November 1995 445
Iowa | Medicine
FEATURE ARTICLE
Contentious debate over Medicare reform contained last month
as the Republicans introduced the Medicare Preservation Act.
The first stop for the bill is the House Committee on
Commerce , of which Iowa Congressman Greg Ganske, a
physician, is a member. Rep. Ganske read this position statement
to the committee on October 2.
Rep. Greg Ganske,
MD
Dr. Ganske, a
reconstructive surgeon
from Des Moines, is the
U.S. Representative from
Iowa’s Fourth District.
He is a member of the
House Committee on
Commerce.
I commend the chairman for a good start
on the structural changes needed to preserve
Medicare. There is much to like in this bill —
free market options, regulatory relief, tort
reform. It also takes courage to acknowledge
that providers and recipients must share in
this process of preserving solvency. However,
this proposal is just a first step.
I am sure that many members of this
committee will have good ideas on how to
improve this bill’s specifics. I, for one, hold
that no political party holds a patent on truth
or knowledge or good ideas. I look forward to
reviewing amendments from both sides of
the aisle. While I may not always agree, I
promise that I will not reject an idea simply
on the basis of party affiliation. The care of
patients is just too important for
back room party politics.
As a physician who has cared
for thousands of Medicare
patients, there are few issues 1
think are more important than the
health of our senior citizens.
There will be pressures on
members on both sides of the aisle to vote a
party line. In this House of The People, no
one should suggest that a member vote other
than their conscience. How could any one of
us live with adverse results affecting the
health of our citizens if we did not vote our
conscience? I call on the chair and the
senior member of the minority party and the
leadership of each party to pledge publicly
and now that they will make no attempt to
make any member vote against their
conscience along party lines.
I look upon this mark-up as a wonderful
way to improve your bill. I will be offering
amendments ranging from consumer
protection to home health care to graduate
medical education to eliminating the
differences in payment between
rural and urban areas. I will also
help defend parts of this bill I
think are good. I know others are
considering offering amendments
on issues such as competitive
bidding.
Besides the structure of this
'The care of
patients is just too
important for
back room party
politics.”
446 Iowa Medicine Volume 85/11 November 1 995
FEATURE ARTICLE
plan, there is the issue of its financing and
the effects it will have. Let’s tell the truth.
We’re in this fight because we’re trying to
balance the budget. The federal budget will
never be brought under control until health
care costs are under control. The Democrats
know this, the President admits this and the
Republican plan tries to implement it.
This brings us to the $ 270 billion spending
reduction goal of this bill. This is the number
that fits. So much for defense, so much for
agriculture, so much for welfare, so much for
health care, so much for tax cuts. If you add
to some, you must subtract from others.
My Democratic colleagues should also tell
the truth. “Don’t worry, be happy”
arguments don’t address the problem. They
may not work politically in the short run and
point in the wrong direction in the long run.
The dilemma we face is exemplified by
statements of Gal Hershner, 68, of Cedar
Rapids, Iowa, a retired school teacher. Mr.
Hershner says, “I feel very strongly that $ 270
billion is too much, too soon in a seven-year
period. It will create a tremendous problem
for Medicare recipients.”
On the other hand, Mr. Hershner says, “I
have five granddaughters and I don’t want
their economic futures jeopardized. I don’t
want to be dependent on my children for
medical care or go back to an era when
people depended on county homes.”
I have worked in this system as a
physician. I represent a large number of
elderly. I have talked with administrators of
small hospitals that are hanging on by a
thread. I believe the goal of $270 billion is
too high in light of the fact that only $30.8
billion of that is marked for structural
changes. The remainder will have to be made
up by providers and beneficiaries.
I guarantee you these reductions would be
bad for quality of health care for our senior
citizens and our working families.
If Medicare and Medicaid cuts are too
deep, hospitals and doctors will shy away
from serving the elderly and the poor or will
try to push costs to the non-elderly, which
could further increase the number of
uninsured. Or the quality of the whole health
care system could decline.
There are three ways we can improve this
health care bill: we can cut spending
elsewhere, we can decrease the size of the
tax cut or we can do both. I believe working
families and senior citizens are served best
by the first approach. The leadership can say
they gave it their best shot with the
Congressional Budget Office, fix these
numbers and then declare a legitimate
victory for common sense. I pray they do.
Congress might even consider adopting
changes in the tax cut that 106 Republican
members requested six months ago. This
common sense approach would limit the
upper caps on the family tax credit and focus
the remaining tax cuts on provisions that
would expand the economy.
I entered medical school over 20 years ago
to help, not hurt people. I became a
congressman to make a difference for
working families and senior citizens.
In medical school, I learned the first
dictum of medicine — premium non nocere
— first, do no harm. I believe this dictum
applies to the markup of this bill. A
tourniquet can prevent hemorrhage, but too
tightly applied can cause gangrene. E3
“We can cut
spending
elsewhere, we can
decrease the size
of the tax cut or
we can do both.”
Iowa Medicine Volume 85/11 November 1 995 447
Iowa [Medicine
GME Seminars
AT A GLANCE
Advertise your continu-
ing medical education
seminars or workshops
in this section by calling
Jane Nieland or Bev
Cor ron at the Iowa Medi-
cal Society, 515/223-
1401 or 800/747-3070,
fax 515/223-8420 or send
copy and payment to
Iowa Medicine, 1001
Grand Avenue, West Des
Moines, Iowa 50265.
Cost is $25 per insertion
up to 10 lines. Deadline
is the first of the month
preceding publication.
CLARKSON MEDICAL
LECTURE SERIES
November 17, 1995
8:00 a.m. - 5:00 p.m.
Advances in
Primary Care:
Building on the
Legacy
Clarkson Hospital
Omaha, Nebraska
(Storz Pavillion)
For more information call
1-800/647-5500, ext 3039
402/552-3039
Did you know . . .
Federal health officials now recommed coro-
nary bypass surgery over angioplasty for dia-
betics with coronary artery disease because of
surprising long-term findings front the world’s
largest study of the two heart procedures.
The National Heart, Lung, and Blood Insti-
tute (NIILBI) recently issued a clinical alert
about patients with Type I or II diabetes who
are being treated with oral hypoglycemic agents
or insulin and have multivessel coronary artery
disease. These patients have a markedly lower
death rate when a first revascularization is
done with coronary artery bypass graft surgery
than with percutaneous transluminal coronary
angioplasty.
The finding comes from the NFILBI-funded
Bypass Angioplasty Revascularization Investi-
gation, an 18-center international randomized
trial. For more information call the NIILBI
Information Center at 301/251-1222.
Is your medical staff or county medical society looking for a CME program idea?
Why not consider the Iowa Medical Society domestic violence videotape!
This 27-minute video is getting rave reviews from physicians and other
health care professionals, clinic managers and domestic violence advocates.
The video contains Iowa domestic abuse experts and is aimed at educating
Iowa physicians on how to manage victims of domestic abuse.
Any IMS member physician may borrow the videotape by calling Chris
McMahon, IMS director of communications, at 800/747-3070 or 515/223-1401.
IMS staff can also provide written materials to accompany the videotape.
Don’t miss out on this opportunity to learn more about domestic abuse in Iowa
and how you can help your patients.
448 Iowa Medicine Volume 85 /II November 1995
Iowa I Medicine
S CIENCE AMD EDUCATION
The Journal
of the lowct Medical Society
Apnea and vomiting in an infant due to cocaine exposure
# Enehomere Okorlwa, MD; Rizwan Shah, MD; Karen Gerdes, MD
The introduction of smokeable cocaine
(crack) in 1980 has resulted in epidemic
cocaine abuse in the U.S. Data concerning
effects of maternal cocaine use on the fetus
and infant have referred mainly to those
effects produced by transplacental transfer of
drugs into fetal circulation and the impact of
perinatal cocaine exposure on infants and
children. Gases of cocaine exposure in
infants resulting from maternal breast milk
have been reported. The following is a case
report of an infant with episodes of apnea and
vomiting as a result of passive exposure to
cocaine.
Case report
A 36-day-old female presented to the
emergency room with a history of multiple
episodes of apnea on that day, each of which
required stimulation. Some of the spells were
associated with vomiting, eye rolling and
limpness. There was no cyanosis, fever, shak-
ing, tremor, diarrhea, upper respiratory infec-
tion symptoms or history of acting ill prior to
the apnea. There was a history of self-limiting
apneic spells at six and 15 days of age. She
was a product of a term pregnancy complicat-
ed by polyhydramnios and was delivered by
Cesarean section for fetal bradycardia. Birth
weight was 5 pounds and 15 ounces. She was
on Similac with iron and had a hepatitis B
immunization five days prior to presentation.
On physical examination at the time of
admission, she weighed 8 pounds and 12
ounces. Significant findings included missing
middle phalanges on both index fingers and
syndactyle of the second and third toes bilat-
eral. While in the emergency room, she had
an apneic episode accompanied by arterial
blood desaturation to 68% and a blank stare,
lasting for less than one minute, which
responded to stimulation.
The results of lab evaluation including
complete blood count, serum electrolytes,
BUN, calcium, iron, phosphorus, creatinine,
uric acid, and alkaline phosphatase were
within normal limits for age. Urine drug
screen was positive for cocaine metabolite
benzoylecgonine (571 ng/ml). No other drug
or drug metabolite was found in the urine.
Chest x-ray, unenhanced head Cl and EEG
were normal. Nasopharyngeal wash for respi-
ratory syncytial virus was negative. The
mother’s urine was positive for benzoylecgo-
nine and tetrahydrocannabinol.
No subsequent apneic episodes were
observed during four days of hospitalization.
The baby was discharged on an apnea moni-
tor to the care of her grandmother following
referral and consultation with child protec-
tive services. Seven months after discharge,
the baby was doing well and had had no addi-
tional apneic spells.
Discussion
Cocaine use in the U.S. is significant.
Twenty percent of 30 million Americans who
tried the drug in 1988 have gone on to be reg-
ular users and 5% compulsive users.1 The
incidence of fetal exposure to cocaine may be
as high as 15% in some communities. In
1987, for example, cocaine was isolated from
the urine of more than 15% of newborn
infants at Harlem Hospital, New York.2
Prenatal cocaine exposure may result in
fetal hypoxia secondary to cocaine-induced
vasoconstriction. Congenital malformations
resulting from vasoconstriction and fetal
hypoxia included dysgenesis of the extremi-
ties, abnormalities of the genito-urinary tract
The IMS
Education Fund
has designated
this article as
the Henry Albert
Scientific
Presentation
Award for
November 1995.
Enehomere
Okorlwa, MD
Rizwan Shah, MD
Karen Gerdes, MD
At the time this article
was written, all th ree
authors were associated
with Blank Children’s
Hospital, Des Moines. Dr.
Okoruwa cun'ently
practices in Council
Bluffs.
Iowa Medicine Volume 85/11 November 1 995 4 49
Iowa I Medicine
Apnea and vomiting in an infant due to cocaine exposure
continued
like prune belly syndrome and hypospadias,
ileal atresia, seizures and cerebral infarction.1 2
Behavioral impairments including poor orga-
nizational responses to environmental stimuli
and depressed interactive behavior have been
reported.1
Postnatal cocaine exposure has been report-
ed to result in generalized seizures, acute hem-
orrhagic diarrhea and cardiovascular collapse,
tachycardia and hypertension and infant
death.3 4 5'6 In addition, some of these infants also
have abnormal sleep patterns, increased irri-
tability, poor feeding habits and tremors.
Apnea associated with vomiting in infancy
is often attributed to gastroesophageal reflux
and aspiration. These common symptoms
should be carefully evaluated with detailed
feeding history, family and social history and
inquiries about drug habits of all caretakers
and household members. While blood and
urine toxicology may not be indicated for all
patients who present with apnea and vomit-
ing, it definitely may be of value in a high risk
population when etiology is unclear, routine
work up is negative and the patient’s symp-
toms resolve while in the hospital and without
any medical intervention.
Our patient and her mother had significant
levels of cocaine metabolites in their urine.
The half-life of cocaine is approximately one
hour. The drug is metabolized by plasma
esterases and the liver microsomal enzyme
system and eliminated in urine mostly as
inactive metabolites. The source of the
cocaine was not breast milk because the
patient was on a regular infant formula. The
most likely source of exposure would be pas-
sive inhalation of cocaine smoke from care
provider’s drug use.
Public education needed
Health care professionals should inform
patients about harmful effects of passive
cocaine exposure on young infants and chil-
dren. An ongoing educational effort for public
awareness regarding prevalence and impact of
passive cocaine exposure should be a priority
among public health professionals. Physicians
need to become more involved in health pro-
motion through public education.
References
1. Wooton, J and Miller, SI: Cocaine: a review. Pedi-
atrics in Review 1994;15:89-92.
2. Bateman, DA and Heagarty, MC: Passive free-base
cocaine (crack) inhalation by infants and toddlers. AJDC
1989;143:25-27.
3. Rivkin, M and Gilmore, HE: Generalized seizures
in an infant due to environmentally acquired cocaine.
Pediatrics 1989;94:1100-01.
4. Riggs, D and Weibley, RE: Acute hemorrhagic diar-
rhea and cardiovascular collapse in a young child owing
to environmentally acquired cocaine. Pediatric Emer-
gency Care 1991;7:154-55.
5. Shannon, M, et al: Cocaine exposure among children
seen in a pediatric hospital. Pediatrics 1989;83:337-42.
6. Mirchandani, IIG, et al: Passive inhalation of free-
base cocaine (‘crack’) smoke in infants. Arch Pathol Lab
Med 1991;115:494-98.
Attention All IMS Emeritus and Life Members
Recently you received a letter regarding Iowa Medicine
magazine. A postcard was enclosed which must be returned
no later than December 1 if you wish to continue receiving
the journal. If you haven’t received the letter and postcard
and want to remain on our mailing list, give us a call at 800/
747-3070 or 515/223-1401 (ask for Jane Nieland or Bev
Gorron).
450 Iowa Medicine Volume 85/11 November 1 995
lnwa
Medical
Group
Management
Association
reasons a medical manager should join . . .
Li nnovative ideas for medical practice management
iyi
I VH edical practice management is our specialty
rowth in your professional career
M
I W IS otivation and education are two of our goals
A
/ m dvocacy for the medical management profession
the IMGMA headquarters office for more information
on how you can benefit from being a member.
800/747-3070 ®r 515/223-1401
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Iowa I Medicine
THE EDITOR COMMENTS
Have I been a
good parent?
wp hirty-eight years ago Jeannette and I
became first-time parents. This was an
I “A.M.”* occurrence; quite different than
with so many in recent years. Now, as I pon-
der over the past 38 years I ask myself,
“Have I been a good parent?” 1 am prompted
i in asking this question by a column by John
l Rosemond which appeared in the Des Moines
Sunday Register on September 17, 1995.
Rosemond, the prolific writer as a family psy-
chologist, avers “Permissive? Nah, today’s
parents are just plain wimps.” He admits to
being a recovering wimp, having in previous
writings admitted how much he learned with
his second child.
“Experts” have caused much consterna-
tion among parents by instructing that chil-
dren must be kept forever happy.
It has been a dictum that to keep
children happy it is no longer suffi-
cient to provide them with the
skills needed to pursue happiness.
Happiness must be ensured by the
modern parent. Rosemond states
that today’s parents are nice folks
and therein lies the problem. They
let their children walk all over them because
they do not feel they have the right to
assertively disallow it. Parents have become
disassertive.
Parenthood, especially with a first child,
can be a tragedy of errors. There is no job so
filled with responsibility which does not
require proven knowledge and expertise. The
*A.M.: after marriage; three years in fact.
child is conceived, born and parented, in
many cases, by totally untried incompetent
individuals who rely on guidance by anyone
willing to provide advice; be it good or bad.
Maternal instinct is not enough. Of course
there are some who have observed their par-
ents actions, but what if they had been
reared under the teachings of the experts
who effectively provided the concepts of
child rearing that are now increasingly being
demonstrated to be without merit?
Now back to my initial question. Was I a
good parent? I must face one fact . . . my par-
ents were very strict, especially my father.
“No” meant “no”; no questions to be asked.
Now, children deserve to have a parent’s
position clarified, but not necessarily that a
child may challenge or disregard
the parent’s decisions. When
faced with reality today, often
children will complain that “no
one ever said it was wrong”. That
is unfortunately a mistake.
I am satisfied with my actions
as a parent. I (we) made mistakes;
we made corrections. The best
testimony I have to rely on was made by that
first child. After being away to college some
number of months and observing attitudes
and behavior of other youngsters, she com-
mented to me, “Thanks, Dad, for being tough
at times. I now know why.”
Can a Dad ask for any more than that? ESI
Parenthood,
especially with
a first child,
can be a
tragedy of
errors.
Marion Alberts, MD
Iowa Medicine Volume 85 / 11 November 1995 453
I’m a practicing physician and I want my patients to know that Medicare will go broke by 2002 unless it’s fixed
now. The AMA has been working 10 years on ways to improve Medicare. Now Congress is about to act, and you
need the straight story about what is really going on. Here are answers to questions patients ask me the most
about the Medicare mess.
1. Does anyone have an answer?
Tire House Leadership has a plan that makes sense, tackles the hard financing problem and is good for patients.
Most important, spending per person will still rise from $4,800 to $6,700 in 2002.
2. Will I have to give up what Medicare already gives me?
No. You can keep the security of traditional Medicare if you want. You won't have to do anything different.
4. How much more will it cost me?
You will pay a little more, but not a lot more.
On average, monthly premiums will rise only
$6 a year over the next seven years. If you
choose a private sector health plan, there
may be expanded benefits and lower out-of-
pocket expenses.
5. Will patients be protected?
Yes. Insurance plans can’t discriminate
against you for a pre-existing condition and
you can appeal if the treatment your doctor
recommends is denied.
Please contact your Represen tative and ask him
or her to suppml the House Leadership's legislation
to strengthen Medicare.
(y(</rrtoi y^o?^t)W3.
Lonnie R. Bristow, MD
President, American Medical Association
American Medical Association
Physicians dedicated to the health of America
3. Can I choose my own doctor and my own
health plan?
Yes. In fact, patients will have more choices, including
traditional Medicare, private insurance plans or a
tax-free medical savings account.
Dr. Lonnie Bristow Speaks
To America’s Patients About
Medicare Reform:
Iowa [Medicine
THE ART OF MEDICINE
Gullibility
The readily-quotable Sir William Osier
remarked in an 1891 speech that “the
desire to take medicine is perhaps the
greatest feature which distinguishes man
from animals,” a wry comment within his
protest at public gullibility over patent medi-
cines and advertising quacks. But being fond
of people, he added “This is yet the child-
hood of the world, and a supine credulity is
still the most charming characteristic of
man.” Such gullibility may be charming, but
its obverse, unfortunately, is mischief or dan-
ger.
A related comment can be found in the
delightful children’s book, The Phantom Toll-
booth by Norton Juster, a “children’s book”
like Alice in Wonderland , full of mature
insight and satire. In it “Dr.
Dischord” has made a diagnosis
unsatisfactory to a character who
protests that “There is no such ill-
ness as lack of noise.” “Of course
not,” replies the doctor, “that’s
what makes it so difficult to cure.
I only treat illnesses that don’t
exist: that way, if I can’t cure
them, there’s no harm done — just one of the
precautions of the trade.” Elsewhere, a char-
acter named the Mathemagician remarks,
“You’ll find . . . that the only thing you can
do easily is be wrong and that’s hardly worth
the effort.”
It is probably because being wrong is so
easy that many people succumb so readily to
advertising. For example, in a medicine/phar-
macy section at the amazingly diverse,
sprawling museum called the House on the
Rock near Dodgeville, Wisconsin, you may
view fascinating 19th century specimens of
uninhibited claims: Tapeworms on sale for
weight-control (“Easy to Swallow and Sani-
tary”); and nearby a bottle of Kickapoo Indi-
an Cure for Tapeworm. See a bejeweled elec-
tric belt that will “Cure all that ails you”; or
try a bottle of Methuselah Pills, with both
subtle and brazen implications of a prolonged
life span. There too in living color from mid-
20th century is the display ad I remember
clearly for Old Gold cigarettes: “The Proof is
in the Smoking — Not a Cough in a Carload.”
And much else.
More than a century has passed since
Osier made his comments. Were
he here to assess contemporary
American society, he would likely
express pleasure and amazement
at many advances, but he could
hardly refrain also from assessing
our world bleakly — with all its
smugness about its literacy,
advanced education and clear-
headed sophistication. In fact, he might sum-
marize the medical profession and the public
using almost the same words he used in
1891. But he might no longer assess our
“supine credulity” as “charming”. One of the
great challenges of medical education and
practice is to avoid gullibility in all its mod-
ern guises. E3
Gullibility may be
charming, but
its obverse,
unfortunately,
is mischief
or danger.
Iowa Medicine Volume 85 /
Richard Caplw, AID
11 November 1995 455
Iowa [Medicine
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Not Just Another Recruitment Ad — Opportu-
nities at North Memorial-owned and affiliated
clinics will give you a shot of adrenaline
because we practice in a care management
environment that FPs, IMs and OB/GYNs
thrive on. Guide your patients through their
entire care process at one of our 25 clinics in
urban or semi-rural Minneapolis locations.
Plus, become eligible for $15,000 on start date.
Interested BC/BE MDs, call 1/800-275-4790 or
fax CV to 612/520-1564.
Iowa, Nebraska
Ifl
and Illinois
Seeking quality physicians inter-
ested in primary care and/or OB/
M
CJ
GYN locum tenen opportunities.
Lh
• Part-time and full-time
• Numerous Iowa, Nebraska and
rj
Illinois locales
s
• Work as much or as little as you
a
desire. You pick the hours and the
0 \
location.
W
• Highly competitive compensation
o
• Paid St. Paul malpractice
-
Send CV or contact
. pi
i Melissa J. Milliken, CMSC
f\ ACUTE CARE , INC.
MnODDQSs '
' PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Mankato Clinic, Ltd. — A progressive group
practice is seeking additional BE/BC physi-
cians in the following specialties: acute/urgent
care, family practice, oncology/hematology,
orthopedic surgery and general internal
medicine practice. The Mankato Clinic is a
70-doctor multispecialty group practice in
south central Minnesota with a trade area
population of +250,000. Guaranteed salary
first year, incentive thereafter with full range
of benefits and liberal time off. For more
information, call Roger Greenwald, Executive
Vice President, at 507/389-8500 or Byron C.
McGregor, Medical Director, at 507/389-8548
or write 1230 East Main Street, P.O. Box 8674,
Mankato, Minnesota 56002-8674.
Assistant Residency Director, Department of
Family Practice, University of Iowa College of
Medicine — The Department of Family Practice
at the University of Iowa College of Medicine is
seeking an ABFP-certified physician to join the
faculty as an Assistant Residency Director.
Responsibilities include curricular design,
procedural skills training and resident
recruitment. The successful candidate will
have practice experience and a minimum of
one year teaching experience at the residency
level and have competency in obstetrics. The
department has a well-established 24-resident
program that is university-administered,
community-based and has admissions at
community and university hospitals. The
program is actively supported by both
hospitals. A new model office facility is being
built and expansion beyond the present one
satellite rural office site is being pursued. As
part of the full academic department,
responsibilities include teaching, research and
patient care. Academic appointment can be in
either the traditional tenure track or a new
clinical track. Scholarly activity is expected
and supported. Appointment and salary
commensurate with qualifications and
experience. The University of Iowa is an
Equal Opportunity/Affirmative Action
Employer. Women and minorities are strongly
encouraged to apply. Submit a letter of
interest and GV to George R. Bergus, MD,
Residency Director, Department of Family
Practice, 2015 Steindler Building, Iowa City,
Iowa 52242; 319/335-8456.
Marshalltown Medical
& Surgical Center
Seeking quality primary care
trained or emergency medicine
physician to practice at MMSC.
• Stellar EM practice
• Full-time, regular part-time and
moonlighting opportunities
• 14K annual volume
• 12-hour shifts, 24-hours/7day
coverage
• Excellentbenefit/bonus packages
• Paid St. Paul malpractice
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE, INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Follow Your Instincts — Like the other 35
physicians in the family medicine department!
They joined one of the nation’s largest
multispecialty groups for very good reasons:
shared call coverage, strong specialty network
and comprehensive salary/benefits. Enjoy
autonomy, freedom from office management
and protection from high insurance premiums.
Opportunities are currently available in a
variety of attractive Iowa and Wisconsin
locations, including department chair of family
medicine at the main clinic in Wisconsin. For
more information, call Susan Pierce at 800/
243-4353.
Emergency Medicine, Des Moines, Iowa —
Opportunity to join an established emergency
medicine practice at Iowa Lutheran, member
of the Iowa Health System. BE/BC in
emergency medicine or primary care specialty
with experience. Gall me to learn more about
our department and generous compensation
package. Contact Larry J. Baker, DO, FACEP,
700 E. University, Des Moines, Iowa 50316;
515/263-5263.
Family Physician — Family Medical Center is
actively recruiting a BE/BC family physician to
join 8 other family physicians and one general
surgeon. Practice opportunity provides 1:9 call
schedule, with full-time hospital ER coverage.
Contract provides for attractive salary and
excellent benefits. Send CV to Linda Cohrt,
Office Manager, 1225 C Avenue East,
Oskaloosa, Iowa 52577 or fax 515/672-2258.
456 Iowa Medicine Volume 85 /II November 1995
CLASSIFIED ADVERTISING
Floyd Valley Hospital
u
ce
s
Seeking quality primary care
trained or emergency medicine
physician to practice at FVH.
* 4300 average volume ER
QJ
• Medical director and staff posi-
J
tions
• Full-time, regular part-time and
moonlighting opportunities
• Weeknight, 12-hour shifts and
weekends
• Highly competitive salary
• Paid St. Paul malpractice
Send CV or contact
1 Melissa J. Milliken, CMSC
asm
1 m
[\ ACUTE CARE, INC.
lil
^ PO Box 515, Ankeny, LA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Ambulatory Care
S3
Clinic
3
Seeking quality physician to prac-
tice either part, full-time or moon-
HH
lighting during residency.
• Primary care, urgent care, oc-
CJ
cupational and sports medicine
S3
• Weekday, weeknight and week-
a
end shifts
• Paid St. Paul malpractice
w
• Excellent benefit/bonus packages
u
Send CV or contact
c ;v-J|CQoao-jOo
'V-?r-H2S55S52S
1 Melissa J. Milliken, CMSC
deDocaDBO
fiSgaaasaEDD
f\ ACUTE CARE. INC.
kWlDBSO D '
' Jaoaaaaat
/looaoocas
* PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Escape from the ordinary! — General surgeon
needed to work in our thriving rural family
practice. Candidate should have skills in C-
section, gyne and laparoscopic surgery. Eight
weeks vacation/CME. Consultants available.
Only group in county with 3 referral centers
one hour away. Uniquely situated on 1-94 half
way between Madison and Twin Cities. Small
town pride, excellent 51-bed hospital, great
schools and recreation including all water
sports, hunting, fishing, cross-country and
downhill skiing. Cohesive group of caring
physicians! Contact or send CV to Gary K.
Petersen, Rrohn Clinic, Ltd., 610 W. Adams
St., Black River Falls, Wisconsin 54615; 715/
284-4311.
Des Moines — IM, FP, PD needed to join
growing elite practice! Above average salaries,
good call coverage, excellent benefits. Call
Mary Latter at 800/520-2028! Job #M141MJ.
Acute Care
| Anesthesia Services, LC
Recruiting MD/DO
Anesthesiologists & CRN As
• Professionally rewarding,
equitable anesthesia practices
• Full-time and part-time
• Incentive-based compensa-
tion and benefits — including
St. Paul medical professional
liability insurance
Send CV or contact
Hi Melissa J. Milliken, CMSC
Iggjjft^crra C4HE. INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
STORM LAKE, IOWA
Rural lakeside community provides unique
setting for self-styled family practice. Em-
ployment with clinic foundation owned by
county hospital means no buy-ins, 1:9 call
coverage with weekend ER relief coverage,
full employment contract with guarantee
and excellent benefit package. You deter-
mine what patients to hand off in an outpa-
tient hospital based referral system of 25
specialists. A+ schools, A+ recreations and
A+ amenities. Send CV or call Darrell
Pritchard, Administrator, Buena Vista
Clinic, Box 742, Storm Lake, Iowa 50588;
collect 712/732-5012; fax 712/732-2538.
Rustic & LInique — Become a member of one of
the largest multispecialty groups in the nation!
This 300+ physician-owned group, based in
southwest Wisconsin, is seeking an additional
family physician for an established clinic in
Iowa. Attractive practice offers shared
coverage, modern local hospital, strong
specialty network and comprehensive salary/
benefit package. Friendly community
surrounded by rolling hills, forest and trout
streams. If you enjoy the ease and security of
small-town living, with convenient access to
metropolitan areas, call Susan Pierce at 800/
243-4353.
Time For a Move?
BC/BE FP, IM, OB/GYN, PEDS
Our promise — Well save you valuable time by
calling every hospital, group and ad in your
desired market. You’ll know every job within
7 days. We track every community in the
country, including 2000+ rural locations. Cedar
Rapids, Des Moines, Quad Cities, Kansas City,
Boston, Chicago, Indianapolis, many more.
New openings daily — call now for details!
The Curare Group. Inc.
M-F 9am-8pm, Sat 1-5 pm EST.
800/880-2028, Fax 812/331-0659
Job #C 1 33M J
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for S2.00
per line with a S30 minimum per insertion.
For members of the Iowa Medical Society
the rate is $ 20 per insertion. Display
classified advertising sells for 825 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85 /II November 1995 457
Iowa [Medicine
CLASSIFIED ADVERTISING
Director, Obstetrics and Gynecology —
Broadlawns Medical Center, a 200+ bed
county/community teaching hospital serving
metropolitan Des Moines and Polk County, is
seeking a well-rounded physician to direct the
ob/gyn department. Activities will include
supervising patient care teaching of family
practice residents, a rotating ob/gyn resident
and medical students in OB (500 births per
year and growing). Department includes
medical office clinical facilities, a Family
Birthing Center with LDRP room accommoda-
tions; a Family Planning Program and mid-wife
positions. Qualifications include an MD or DO
degree, board certification or active candidacy
of the American Board of Obstetrics and
Gynecology, extensive practice experience and
the ability to direct staff and programs to
support the service and education goals of the
facility. Clinical teaching experience is
desirable. Post offer/pre-employment physical
and drug screen required. This is a University
of Iowa clinical appointment. Take the
challenge and join our team! If interested
contact D.J. Walter, MD, 1801 Hickman Road,
Des Moines, Iowa 50314; 515/282-2203.
Minorities and women encouraged to apply,
Broadlawns is an Equal Opportunity/Affirma-
tive Action Employer.
Clarkson Family Medicine — Clarkson Family
Medicine opened its doors July 1, 1991. We
have filled in the Match Program every year
since then and have expanded from a 12-
resident program to an 18-resident program in
1995. We have seen our graduates, as a group,
score in the top 10% nationally on the in-
training exam. We currently have 4 full-time
family practice faculty, one obstetrician, one
pediatrician and full-time behavioral science
coverage, including 2 part-time psychiatrists.
In order to provide the training necessary to
prepare our residents for rural practice,
including extensive OB and procedural
experience, we are recruiting 2 additional
family physician faculty. Requirements
include practice and/or teaching experience,
strong OB background and a desire to
participate in a new, exciting and growing
residency program. Responsibilities and
salary are negotiable and based on experience.
Clarkson Hospital takes pride in being a
smoke-free environment and does not hire
applicants who use tobacco products. EOE.
Send CV and/or letter of inquiry to Richard A.
Raymond, MD, Director, Clarkson Family
Medicine, 4200 Douglas Street, Omaha,
Nebraska 68131; 402/552-2045.
Conrad, Iowa — Marshalltown Medical &
Surgical Center seeks board certified physician
or recent graduate of an accredited residency
program for a partnership opportunity in
Conrad, Iowa. An exceptional rural commu-
nity, Conrad is located in central Iowa, only 60
minutes north of Des Moines. A progressive,
civic-minded town, Conrad has an active Main
Street Program, healthy retail sector, quality
public schools and many amenities which you
would expect to find in a larger community.
Residents recently surpassed a $150,000 fund
drive to build a new water park complex.
Clinic staff includes two full-time physicians
and two part-time physician assistants. The
2,500 square foot facility houses up-to-date
laboratory and x-ray equipment, as well as
computerized billing and appointment
scheduling capabilities. You will earn
competitive salary/benefits, paid interview/
relocation expenses and an option for a
forgivable loan. For more information contact
Shelley Shiflett, Marshalltown Medical &
Surgical Center, 800/542-0014 or send or fax
resume to 3 South 4th Avenue, Marshalltown,
Iowa 50158; fax 515/754-5181.
Internal Medicine and Family Practice
Opportunities — Rural lake country commu-
nity is seeking the above practitioners to join
an active 13-physician multispecialty group.
Quality, comfortable living environment,
multiple recreational activities, fine educa-
tional opportunities and cultural activities
abound. Opportunity includes relaxed call,
liberal salary and exceptional benefits. Send
curriculum vitae or inquiries to Lake Region
Clinic, PC, Attn: Joel Rotvold, PO Box 1100,
Devils Lake, North Dakota 58301 or call 800/
648-8898 for further information.
Advertising Index
Bemie Lowe & Associates 426
Blue Cross Blue Shield 430
Brainerd Medical Center 458
Clarkson College 448
Emergency Practice Associates 459
Franciscan Skenip Healthcare 459
IMGMA 451
IMS Services 435
Josephs 452
Medical Protective Company 463
Medical Management Strategies ....435
MMIC 464
North Iowa Mercy Health Center ..439
OceuSystems, Inc 439
U.S. Air Force 459
INTERNIST . . .
Want to share call with eight other internists and live in the
Brainerd Lakes Area? Immediate and future openings
available at Brainerd Medical Center.
Brainerd Medical Center, P.A.
• 30-physician independent multispecialty group
• Located in a primary service area of 40,000 people
• Almost 100% fee-for-service
• Excellent fringe benefits
• Competitive compensation
• Exceptional services available at 162-bed local hospital
— St. Joseph’s Medical Center
Brainerd, Minnesota
• In the middle of the premier lakes of Minnesota
• Less than 2 1/2 hours from the Twin Cities, Duluth and
Fargo
• Large, very progressive school district
• Great community for families
Inquiries from general internists or internist with subspecialty
interest in pulmonology or rheumatology welcomed.
Call collect to administrator:
Curt Nielsen
Brainerd Medical Center, P.A.
218/828-7105 or 218/829-4901
2024 South 6th Street, Brainerd, Minnesota 56401
458 Iowa Medicine Volume 85/11 November 1 995
Franciscan Skemp
Healthcare
MAYO HEALTH SYSTEM
La Crosse, Wisconsin- Exciting opportunities are
available for BE/BC physicians in the following areas:
• Family Practice • Urgent Care • Pulmonology
• Cardiology • Neurology • Neurosurgery
• Orthopedics • Neonatology
• Emergency Medicine
Franciscan Skemp Healthcare, an integrated delivery
network, serves a population base of 350,000. We
include three hospitals and 12 clinics with over 100
active medical staff members.
La Crosse is located in scenic Mississippi River bluff
country with excellent fishing, hunting, boating. Ideal
family-oriented environment. Good public and private
schools.
Contact:
Tim Skinner, M.S.Ed., or Bonnie Nulf
Franciscan Skemp Healthcare
800 West Avenue South
La Crosse, WI 54601
Phone: (800) 269-1986
Fax: (608) 791-9898
EMERGENCY MEDICINE
I Iowa
North & Central Minnesota
Q Full- and part-time
Q Comprehensive benefit packages
3 Paid malpractice
Q Professional environments
Q Ample time for family and leisure
Q Progressive physician-owned group
Q Excellent compensation packages
Q Various locations
Q Reasonable housing in safe
communities
Q Top-notch school systems
Q Quality lifestyles
Call 1 -800 458-5003
Emergency Practice Associates
or send CV to Sheila Jorgensen
P.O. Box 1260, Waterloo, IA 50704
BE AN AIR FORCE
PHYSICIAN.
Become the dedicated physician you
want to be while serving your country in
today’s Air Force. Discover the tremen-
dous benefits of Air Force medicine. Talk
to an Air Force medical program manag-
er about the quality lifestyle and benefits
you enjoy as an Air Force professional,
along with:
• 30 days vacation with pay per year
• Dedicated, professional staff
• Non-contributing retirement plan if
qualified
Today’s Air Force offers the medical envi-
ronment you seek. Find out how to quali-
fy. Call USAF HEALTH professions
TOLL FREE 1-800-423-USAF
Iowa [Medicine
Professional Listing
Allergy
Emergency Medicine
Internal Medicine
John A. Caffrey, MI), PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MD
R.K. Agarwal, MI)
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatric and Adult Allergy, PC
Veljlto K. Zivkovich, MD
Robert A. Colman, Ml)
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
Dermatology
Robert J. Itarry, Ml)
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery > of Skin
Fort Dodge Mcdieal Center, PC
Carey A. Bligard, MD, FAAD
James D. Bunker, MD, FAAD
804 Kenyon Road
Fort Dodge 50501
515/574-6850
Electrodiagnosis
John Milner-Brage, MD
208 St. Francis Professional Building
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Family Practice
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Care
Associates, PC
Daniel II. Gcrvich, MD
Daniel J, Schrocdcr, MI)
Ravi K. Vcmuri, MD
Infectious Diseases
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Infertility
Mid-Io>va Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
IVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
Fort Dodge Medical Center, PC
Cardiology
Samir G. Artoul, MD, FICC
515/574-6840
Gastroenterology
Kenneth \V. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, DID
Richard II. Brandt, MD, ABIM
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Mcdieal Clinic Neurology
Andrew C. Peterson, MD
Laurence S. Krain, DID
600 7th Street SE
Cedar Rapids 52401
319/398-1721
Neurology , EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Dlcdieal Center, PC
Jugal T. Raval, DID, D1BBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery'
James R. Lamorgcsc, MD
Loren J. Mmiw, DID
600 7th Street, SE
Cedar Rapids 52401
319/366-0481
Practice limited to Neurosurgery
Hosting Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
460 Iowa Medicine Volume 85 /II November 1995
PROFESSIONAL LISTING
Neurosurgical Services LLP
Robert Hayne, Ml)
Thomas A. Carlstrom, Ml)
David J. Boarini, MI)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MI)
S. Randy Winston, MD
Douglas R. Koontz, MD
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery
Chad I). Ahernathev, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery >
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, MD
John M. Gracther, MD
Gilbert W. Harris, Ml)
James A. Davison, MD
Norman F. Woodlief, MI)
Erie W. Bligard, MI)
David I). Saggau, MI)
Steven C. Johnson, MD
Todd W. Gothard, MI)
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
i
! Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Ophthalmic Associates, PC
Robert I). Whinerv, Ml)
Stephen II. Wolkcn, MD
Robert B. Goffstein, MI)
Lyse S. Strnad, MD
John F. Stamlcr, MI), PhD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MD
Emile C. Li, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6880
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MD
Randall S. Brcnton, MD
James L. Duinmctt, MD
Mick E. Yandcn Bosch, MI)
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., Ml)
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Otolaryngology
Iowa ENT, PC
Thomas A. Erieson, MD
Marshall C. Greiman, MD
Steven R. Herwig, DO
Thomas O. Paulson, MI)
Mark K. Zlah, MD
1-800/248-4443
1215 Pleasant, Suite 408
Des Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton, Indianola,
Oskaloosa, Guthrie Center, Knoxville
Wolfe Clinic, PC
Michael W. Ilill, MD
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Iowa Orthopaedic Center, PC
Marshall Flapan, MD
Sinesio Misol, MI)
Joshua 1). Kimclman, DO
Timothy G. Kcnncv, Ml)
Lynn M. Lindaman, MI)
Jeffrey M. Farber, MD
Kyle S. Gallcs, MD
Seott A. Meyer, Ml)
Cassini M. Igram, MD
Rodney E. Johnson, MD
Martin S. Rosenfcld, DO
Teri S. Formanek, MD
Stephen M. Naruto, MD
Donna J. Bahls, MD
Jill R. Meilahn, DO
Jacqueline M. Stoken, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery >, Allergy
( Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: 810.00 first
3 lines; 82.00 each additional line. Billed
yearly. May be prorated. Send or fax
copy to Iowa Medical Society, 1001 Grand
Avenue, West Des Moines, Iowa 50265-
3599, fax 515/223-8420.
Iowa Medicine Volume 85 /II November 1995 461
Iowa [Medicine
PROFESSIONAL LISTING
Iowa Head and Neck Associates, PC
Robert T. Brown, MI)
Eugene Peterson, MD
Richard B. Merrick, MD
Peter V. Boesen, MD
Robert R. Updegraff, MD
3901 Ingersoll
Des Moines 50312
515/274-9135
Dubuque Otolaryngology-Head & Neck
Surgery, PC
Thomas J. Benda, Sr., MD
James VV. White, MI)
Craig C. Herthcr, MD
Thomas J. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Otologic Medical Services, PC
Roger A. Simpson, MD
Guy E. McFarland, MD
Thomas F. Viner, MD
Douglas E. Dawson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery and Head and
Neck Surgery
Phillip A. Finquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery,
Facial Plastic Surgery, Head
and Neck Surgery
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgese, MD, FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSW, ACSW, Program
Director
6u0 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheu matology
Pediatries Pulmonary Medicine
Fort Dodge Medical Center, PC
Ronald C. Sanders, MD
Rosana M. Diokno, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6855
Perinatology
I)es Moines Perinatal Center, PC
Neil T. Mandsager, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Chest, Infectious Diseases & Critical Care
Associates, PC
Roger T. Liu, MI)
Steven G. Berry, Ml)
Donald L. Burrows, MD
Michael Witte, DO
Gerard A. Matvsik, DO
Donald R. Shumate, DO
1601 NW 114th, Suite 347
Des Moines 50325-7072
24 Hour 515/224-1777
Surgery
Wendell Downing, MI)
1212 Pleasant Street, Suite 410
Des Moines 50309
515/241-5767
Diseases and Surgery of the Colon and
Rectum
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice 1). Schncll, Ml)
Farccduddin Ahmed, MD
Arthur B. Searle, MD
Bogdan E. Krvsztofiak, MI)
Rehabilitation Medicine Associates
William I). dcGravcllcs, Jr., MI)
Charles F. Dcnhart, MI)
Marvin M. Hurd. MD
William C. Koenig, Jr., MD
Karen Kicnkcr, MD
Todd C. Troll, MD
Lori A. Sapp, MD
Younkcr Rehabilitation Center
Iowa Methodist Medical Center
1200 Pleasant
Des Moines 50308
515/241-6434
Fort Dodge Medical Center, PC
Dan P. Warliek, MD, FACS
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Vascular Surgery
Fort Dodge Medical Center, PC
Marshall C. Hunting, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6865
Urology
Fort Dodge Medical Center, PC
Steven P. Hoff, MD
800 Kenyon Road
Fort Dodge 50501
515/573-4141
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
462 Iowa Medicine Volume 85 /II November 1995
Iowa I Medicine
THE PRESIDENT COMMENTS
AMAs role in the
Medicare reform bill
At the recent North Central Medical Con-
ference meeting, I had the opportunity
to hear AMA President Lonnie Bristow
deliver a few comments on a variety of sub-
jects, primarily Medicare reform and the
AMA Board of Trustees.
I was especially interested in the AMA’s
role in development of the Medicare reform
bill. Last January, Newt Gingrich invited AMA
leaders and other health care organization
leaders to a meeting. lie asked them to return
in two weeks with their ideas and “to be
bold”. As many of you know, the AMA had
been working on a plan for some time and was
ready for this opportunity. About 80% of the
AMA plan was adopted. Many of you are also
familiar with the bill’s provision for liability
limitation of $250,000 for non-eco-
nomic loss. This particular provi-
sion also guarantees that most of
the dollars will go to the patients
rather than trial lawyers. There is
regulatory relief from Stark 1 and II
and from CLIA. Patient protection
is also addressed with regard to
managed care plans and guarantees
that patients be informed as to rights and
responsibilities. There is also encouragement
for physician-sponsored networks to compete
with insurance companies and other health
care networks.
What about the “deal” the AMA supposed-
ly made with the GOP leadership regarding
the Medicare conversion factor? Physicians
account for approximately 23% of Medicare
Part B expenditures. However, over the last
13 years we have been the recipients of 32%
of the cuts in this area. The average overhead
for a physician is 50% and the proposed con-
version factor would set Medicare payments
at only 10-20% above that. This small margin
could result in a lack of access for Medicare
patients. As Dr. Bristow said, “They listened
and agreed to attempt to increase the con-
version factor.” The conversion factor was
increased from $34.60 to $35.42. This
doesn’t seem like a great deal. However,
when coupled with the new formula for vol-
ume growth, over the next seven years this is
projected to add up to $20 billion more than
under current law. That was the “deal” that
the press made so much of. It is a good
example of the AMA advocacy for
physicians and patients.
Dr. Bristow also made another
important point. The AMA has
limited its proposals and involve-
ment to Medicare and properly did
not become involved in the debate
over the tax cut. This is a separate
issue; the AMA is bipartisan.
I had the opportunity to visit with Dr.
Bristow one evening. He is an engaging, artic-
ulate, warm and friendly man. I asked him
what he does in his spare time (as if he had
any). He hesitated slightly and then said
when he has the time (on the road I assume)
he often visits an inner city school and talks
with the children. He is my kind of guy. I am
pleased that he is our president. ^
Over the next
seven years
this amounts to
$20 billion
more than under
current law.
Joseph Hall, MD
Iowa Medicine Volume 85 / 12 December 1995 471
600 Iowa medical practices
are covered by the . . .
STATEWIDE
PHYSICIANS
HEALTH
INSURANCE
PROGRAM
It may be right for you!
We’ll help you find out!
Over 10,000 individuals are protected by the Iowa
Medical Society-sponsored STATEWIDE PHYSI-
CIANS HEALTH INSURANCE PROGRAM. It'sstable
coverage with competitive rates.
If you’re not one of the SPHIP insureds, you may want
to explore the program’s many coverage options —
both medical and dental. We'll be glad to supply
information specific to you and your practice.
Endorsed and overseen by the IMS for its members,
their families and employees, the SPHIP has been
underwritten by Blue Cross Blue Shield of Iowa since
the program began 40 years ago. Today’s program
incorporates various deductibles and coverage for-
mats.
Please call Ruth Clare or Terri DeGroot for informa-
tion about the program.
BERNIE LBWE & A55BEIATE5. INE.
Insurance Administrators to Professional Associations &
Universities and Colleges
515-E2Z-BB11 1-B00-94EF4718 FAX 515-EPB-B915
E7DO Westown Parkway. Suite 410
\Afact- nm= A/lninoc nniPKFciziii
Iowa Medicine
SPECIAL TRIBUTE
Farewell to a friend
Tina Preftakes joined the staff of the Iowa
Medical Society in June of 1952, fresh
from the University of Iowa with a
degree in journalism. Her original salary card
lists her job as “Sec — tv”. Translated, it was
Tina’s responsibility to produce a live
television show featuring real doctors in real
practice situations.
It is speculated that this experience gave
Tina the nerves of steel in the face of
calamity which she retained throughout her
years at the IMS. As time went on, she
progressed upward through various positions
and titles — administrative assistant, exec-
utive assistant, assistant director and, finally,
assistant executive vice president. This list is
incomplete; the important thing to know is
that Tina accomplished whatever was asked
of her with the utmost efficiency and
unfailing good humor.
When people who have worked closely
with Tina are asked to
describe her, they
invariably mention the
fact that the IMS has
been such a big part of
her life. They talk about
her loyalty to Iowa
physicians and the
difference she made for
so many of them.
“The efficiency and
quality of staff support
Tina provided excelled
over all the others,” says
Dr. Paul Seebohm,
associate dean with the
UI College of Medicine and past IMS
president. “No one is better at anticipating
problems and tending to details than Tina.”
“Tina could always see the big picture. Her
professionalism and dedication have truly
benefited Iowa physicians,” comments Dr.
Ilormoz Rassekh. Dr. Rassekh, a Council
Bluffs psychiatrist, is also a past IMS pres-
ident and one of the many Iowa physicians
Tina counts among her lengthy list of friends.
IMS staff members — who think of Tina as
much more than a co-worker — say she is the
most giving person they know. They praise
her perpetual willingness to go the extra mile
for IMS members and for her friends.
Even more significant, all her co-workers
have learned much from the example Tina
has set, day in and day out, for 43 years.
Through Tina, we saw the importance of
respecting everyone’s opinions and feelings.
As we bid Tina farewell, we hope that once
in awhile we will still
hear her ready laugh and
those wonderful stories
about her childhood in
Clarion. We hope that
occasionally we might
get one of those silly
notes signed with her
own “TP” logo.
Tina, we wish you a
happy and productive
retirement. See you
back at the ranch. HI]
Iowa Medicine Volume 85 / 12 December 1995 4 73
Iowa | Medicine
IMS Update
CURRENT ISSUES
AT A GLANCE
The harmful effects of
alcohol , tobacco and
other drugs on unborn
babies is the topic of a
new 11-minute video
available from the Iowa
Substance Abuse Infor-
mation Center. The
video was filmed in
Iowa and is ideal for
physicians’ reception
areas. To order a com-
plimentary copy, call
800/247-0614.
•
The Iowa Distance
Learning Association’s
third annual conference
is planned for February
29 through March 1,
1 996 at the University of
Iowa Memorial Union.
Telemedicine and video-
conferencing will be on
the agenda. For further
information on how to
register, call 515/271-
2182.
•
There has been a sharp
increase in use of
methamphetamines by
Iowans. Of those seek-
ing treatment at sub-
stance abuse centers,
7.3% listed meth as their
primary problem, com-
pared to 2.2% the year
before.
Mark your calendars
Mark your calendars now for the
1996 IMS Annual House of
Delegates and Scientific Session
Friday — Sunday, April 19 — 21
Embassy Suites • Des Moines
IMS offices up for election in 1996
Offices up for election at the Iowa Medical
Society’s 1996 Annual Meeting April 20-21
include: (The length of each term is in paren-
thesis, along with the name of the physician
now holding the office.)
PRESIDENT ELECT (1) — William McMillan, MD
VICE PRESIDENT (1) — Sterling Laaveg, MD
TRUSTEE (3) — Harold Miller, MD
HOUSE SPEAKER (1) — Donald Kahle, MD
VICE SPEAKER (1) — Tom Throckmorton, MD
AMA DELEGATES (2) — Clarence Denser, Jr.,
MD; Donald Young, MD; Bruce Trimble, MD
AMA ALTERNATES (2) — Thomas Graham, MD
Judicial Councilors are elected by a dis-
trict wide vote of eligible IMS voting mem-
bers. The names of physicians elected as
Judicial Councilors will he submitted for con-
firmation by the 1996 House of Delegates.
Details will be sent to county medical soci-
eties due to elect councilors in 1996.
Up for election are:
DISTRICT 2 — Jamal Hoballah, MD
DISTRICT 4 — Albert Coates, MD
DISTRICT 5 — Ross Madden, MD
DISTRICT 10 — Michael Disbro, MD
DISTRICT 11 — C. David Smith, MD
DISTRICT 14 — Stephen Richards, DO
The IMS Program Committee has been
making plans for the 1996 Scientific Session,
which will begin on Friday, April 19 at the
Embassy Suites, in conjunction with the
House of Delegates.
Tentative topics for the Scientific Session
include: Grave’s Disease, genetic engineering
in cystic fibrosis, vascular disease in the
elderly and youth violence.
IMS Board meets with CHMIS committee
The IMS Board of Trustees met recently
with the CHMIS Executive Committee. Read
details of the discussion (and important infor-
mation on signing a contract with a CHMIS
network) on page 476 of this issue. Dul
Specialty Society Update
The Iowa Association of County Medical
Examiners met Friday, November 3 at the
Sheraton Inn in Cedar Rapids. Dr. R.C. Wooters,
retired Polk County Medical Examiner, was hon-
ored by Governor Terry Branstad at the group’s
luncheon.
The Iowa Oncology Society annual fall member-
ship meeting was held at the McFarland Clinic in
Ames Friday, October 27. Dr. Joseph Bailes of the
American Society of Clinical Oncology was guest
speaker. New oncology practice arrangements and
Medicare reform were also discussed.
A record number of members attended the Iowa
Psychiatric Society annual meeting October 27-28 in
Iowa City. The role of serotonin in psychiatric illness
was part of an excellent program planned by Brian
Cook, DO. Terrence Augspurger, MD was nominated
as IPS president. A committee plans to meet
December 6 with Merit Behavioral Health
Corporation (formerly Medco) regarding continuing
concerns. Committee members are: Michael Egger,
MD; Loren Olson, MD; James Pullen, MD; S.
Ravapati, MD; Tom Garside, MD; and Cindy Hoover,
MD.
The Iowa Medical Group Management Association
continues developing a uniform credentialing
form for physicians applying for participation with
insurance companies, hospital privileges or
licensing. A meeting of organizations interested in
this project was scheduled for November 28.
474 Iowa Medicine Volume 85 / 12 December 1995
Iowa [Medicine
Futures
Iowa Health Reform Transition Team
The Iowa Health Reform Transition Team
held its final meeting October 26. The team
has worked for the past three years to guide
and advise state policy and lawmakers on
health reform options and initiatives in Iowa.
David Lyons is chairman of the team;
William Eversmann, MD represented IMS.
Much of the team’s work has been funded by
the Robert Wood Johnson Foundation.
It is hoped Iowa will win another RWJ
grant to undertake additional initiatives in
the future.
Attention: physician entrepreneurs
Physician Entrepreneurship: Principles,
Practices and Tactics for Business Plan
Development is the focus of a program to be
held January 8-10 on the Northwestern
University Campus.
Presented in conjunction with Northwest-
ern’s Kellogg Graduate School of Manage-
ment, the intensive three-day program high-
lights how to develop an effective business
plan, how to raise capital, entrepreneurial
finance and keys to developing strategic
alliances. The cost of the program (including
all meals, housing, registration and course
materials) is $2,000 for AMA members;
$3,000 for nonmembers.
For more information or to register, call
Katherine Rouse at 312/464-4274.
AMA president meets with senior citizens
Lonnie Bristow, MD, AMA president, met
recently with 800 senior citizens in a Calif-
ornia retirement community and urged them
to support the GOP’s Medicare reform pack-
age. Dr. Bristow said the package is an oppor-
tunity for retirees to protect their children.
Meanwhile, lobbyists for the elderly, the
disabled and all sorts of health providers
were converging on Capitol Hill as the full
Senate geared up for a vote on Medicare
reform. As of press time, Republican leaders
were working to overcome GOP divisions
caused by changes needed to win Senate
approval for the Medicare proposal.
There was speculation the president will
veto any bill the GOP sends him, so GOP
leaders asked him to come to the bargaining
table. Clinton refused and told Republicans
once again to back off cuts in vital areas like
Medicare. Republicans reportedly lack the
votes to overcome a presidential veto.
The Senate Finance Committee amended
its Medicare reform proposal to allow physi-
cian and hospital networks to contract
directly with the program, putting the Senate
Republican proposal more in line with the
House version, which would ease regulations
that hinder development of such networks.
Medical Records Confidentiality Act
Three LTS senators have introduced the
Medical Records Confidentiality Act, which
would govern the use of medical treatment
and payment records in written and elec-
tronic form. The measure would insure that
patients have the right to inspect their health
records while safeguarding personal data to
keep the information from getting into the
wrong hands.
In Iowa, the CHMIS Governing Board has
said that patient-specific information will
never be released from the CIIMIS. There
reportedly has been no discussion of this fed-
eral proposal by the CHMIS Board.
HMO’s have 'spillover’ effect
Increased enrollment in Medicare HMOs
means decreased costs, not only through
managed care savings, but through a
‘spillover’ effect that lowers Medicare fee-for-
serviee costs, according to a study by the
IIMO trade group, GIIAA. El
CURRENT ISSUES
AT A GLANCE
According to a recent
study reported in JAMA
more than one-third of
Americans under age 65
are uninsured or lack
adequate coverage.
•
Under a block grant sce-
nario, states will be
free to scrap existing
Medicaid programs in
favor of managed care.
Already, 49 states are
poised to launch or
expand such programs.
If Congress succeeds in
cutting Medicaid by
5182 billion, states will
face a difficult choice —
allocate more money to
Medicaid or cut bene-
fits. Some experts are
predicting widespread
hikes in state taxes in
the future. Iowa Medi-
caid staff are studying
options in order to be
ready once federal deci-
sions are made.
Iowa Medicine Volume 85 / 12 December 1995 475
Iowa | Medicine
CURRENT I S $ y E S
on your horizon July 1, 1996
YOUR representatives
on state GHMIS
committees:
CHMIS
Governing
Board:
Dale Andringa, MD
Des Moines
515/241-4102
Beth Bruening, MD
Sioux City
712/233-1529
CHMIS advisory
committees:
Communications/
Education
Laine Dvorak, MD
Clarence Denser, .1 r. , MD
Data Advisory
John Brinkman, MD
Ethics/Confidentiality
Charles Jons, MD
Quality Review
Elie Saikaly, MD
William Langley, MD
Technical Advisory
Mark Purtle, MD
IMS CHMIS
Committee:
Terrence Briggs, MD (chair)
IMS staff:
Ed Whitver
Barb Cannon Heck
Dean Gillaspey
CHMIS Update
This CHMIS Update is a regular feature in Iowa
Medicine, and is part of the Iowa Medical Society’s
effort to keep you informed about CHMIS.
The IMS Board of Trustees met with the
GHMIS Executive Committee on October
18. The Board and the Committee dis-
cussed the following issues of importance
to Iowa physicians:
1. Electronic insurance eligibility verifi-
cation will begin July 1, but it is uncertain
what will be included in the initial system.
Eligibility can encompass many features.
A work group of providers and payers is
defining minimum elements to include in
an eligibility system on July 1, as well as
future expansion, while attempting to bal-
ance cost to benefits.
2. ERISA plans (self-administered
health plans) are not obligated to partici-
pate in CHMIS since they are governed by
federal law. They have been encouraged to
participate voluntarily.
3. The data repository contractor will
have only six months to install hardware
and software, hire employees and test the
system between providers, payers, net-
works, etc. This short start up time frame
is a concern to members of the CHMIS
Governing Board, who now say July 1 is a
starting point for CHMIS implementation.
4. The cost of CHMIS remains an elusive
topic. Much depends on the cost to operate
the data repository, which will not be clear
until the contract is awarded this month.
The IMS maintains the position that
CHMIS should reduce administrative costs
for physicians and that cost should not be
borne disproportionately by providers.
5. Data confidentiality will be a key con-
cern to physicians as long as the CHMIS
exists. The IMS Board of Trustees ques-
tioned CHMIS representatives at length
regarding patient confidentiality issues.
6. Other provider groups will probably
begin CHMIS participation by July, 1997.
CHMIS representatives said it is desirable
for everyone to gain experience and
improve the process before other
providers are brought in.
At the October CHMIS Governing Board
meeting, it was announced that 19 entities
attended the data repository bidders con-
ference. Bids are due November 15.
Important news about CHMIS networks . . .
Physicians are advised not to sign a contract with a CHMIS network
UNLESS THE CONTRACT HAS AN ESCAPE CLAUSE
Criteria for certification of CHMIS networks are now complete and potential network
vendors are beginning the process of earning CHMIS certification. The process of earning
final, unconditional CHMIS certification will take a year or longer. As a result, there will
be no fully-certified networks by July 1, the deadline date for CHMIS implementation.
However, members of the CHMIS Governing Board say some networks will be granted
“provisional” certification in time for the July 1 deadline. Companies who have applied
for full CHMIS certification (and have been granted “provisional” status) could begin mar-
keting campaigns to Iowa physicians as early as January or February of 1996. This means
that if a physician signs with a “provisional” network and that network does not ulti-
mately receive full certification, the physician will be forced to find a new network.
Consequently, physicians should make sure there is an ’immediate termination’
clause in any contract signed with a “provisional network”.
Watch the February issue of Iowa Medicine for guidelines on selecting a network.
For more information about CHMIS networks, call Ed Whitver of the IMS staff,
515/223-1401 or 800/747-3070.
476 Iowa Medicine Volume 85 / 12 December 1995
Iowa [Medici ne
CURRENT ISSUES
Legislative Affairs
Pensions and malpractice lawsuits
Under current Iowa law, pensions (except
IRAs) are exempt from tort claimant credi-
tors, according to a recent legal opinion pre-
pared at the request of the IMS.
Iowa law provides for the exemption from
execution by creditors of the cash surrender
value of life insurance; a benefit or indemni-
ty paid under an accident, health or disabili-
ty insurance policy; social security benefits;
unemployment compensation; veteran’s ben-
efits; alimony maintenance or support and
pensions; and annuities or similar contracts
triggered by illness, disability, death, age or
length of service.
Accrued dividends, cash surrender value
or interest in a life insurance policy is also
exempt if the beneficiary is the person’s
spouse, child or dependent.
A payment or portion of a payment under
a pension, annuity or similar plan or contract
on account of illness, disability, death, age or
length of service is exempt, unless the pay-
ment results from contributions to the plan
within one year prior to the filing of a bank-
ruptcy petition.
Physicians are cautioned that independent
and individualized analysis is necessary to
determine the exempt status of any individ-
ual’s assets.
For a copy of the complete legal opinion on
exemption of pensions from tort creditors,
call Chris McMahon at the IMS, 515/223-1401
or 800/747-3070.
Legislature convenes January 8
January 8 is the opening day of the 1996
legislative session. While major health issues
are not likely to be at the top of the agenda,
there are always plenty of issues that arise to
keep IMS lobbyists busy.
The IMS is continuing to work with sena-
tors to encourage their support of I IF 394, the
IMS statute of limitations for minors bill
which passed the House in 1995.
Legislators have been requested to draft
bills relating to insurance coverage for obstet-
rical care and patient access to medical
records.
IMS Council discusses OB stay
At its September meeting, the IMS
Executive Council adopted the following posi-
tion which addresses the trend toward
reduced coverage for hospital stays following
continued
IMS STAFF ‘ON THE ROAD’ MEETING WITH MEMBER PHYSICIANS
An IMS staff “road show”, which includes a videoptape presentation on the IMS 1996 legisla-
tive priorities, is available to Iowa physicians who want information on the Iowa Medical Society’s
priorities for the coming year in several areas. The tape is about 20 minutes long. On the video,
physicians involved in the IMS legislative program discuss the IMS priorities and the impact of
grass roots involvement in the political process.
As scheduling permits, Paul Bishop, IMS legislative liaison, will be on hand to answer questions
after the tape is shown. Ed Whitver, manager of health care data and information, and Tom Leners,
a representative of Midwest Medical Insurance Company, will also be on hand to answer questions
about CHMIS, data collection efforts and the liability insurance market.
To borrow a videotape or to arrange for a program in your area, call Paul Bishop at the IMS,
515/223-1401 or 800/747-3070.
AT A GLANCE
The FDA will propose
ndes to ban distribution
through vending mach-
ines (except in bars)
and stop tobacco com-
pany sponsorship of
sporting events and
concerts. Until the issue
of whether FDA has a
right to regulate tobac-
co is settled, court bat-
tles will continue.
•
According to Modern
Healthcare, during the
last election cycle the
American Medical Asso-
ciation was the most
balanced with regard to
political contributions.
From January of 1993
to November 1994, 58%
of the AMA’s political
action funds went to
Republicans; 42% went
to Democrats. The Amer-
ican Hospital Assoc-
iation split was 65% for
Democrats and 35% for
Republicans. Other org-
anizations named —
including associations
representing optome-
trists and nurses — con-
tributed nearly 75% of
their PAC funds to
Democrats.
Iowa Medicine Volume 85 / 12 December 1995 477
Iowa | Medicine
CJJRR E NT ISSUES
Legislative Affairs
continued
the birth of a baby:
IMS believes the decision on length of hos-
pital stay following the birth of a baby
should be decided by the physician and
patient based on the needs of the mother and
baby.
The IMS should attempt to work with key
organizations on this issue, including third
party payers, employer organizations and
other provider groups.
The Council left open whether or not to
support legislation on this subject pending
discussions with payers. Concerns were
voiced by many Council members about the
undesirable precedent of legislating length of
hospital stay. The situation will be evaluated
once the legislative session has begun.
Taxes will be an issue, too
Taxes are expected to be a big item for leg-
islators as they consider whether to provide
tax relief for Iowans, spend revenue surplus-
es on needed infrastructure improvements or
wait to see what impact possible federal
changes in Medicaid and welfare programs
have on Iowa.
Rural health grants announced
A dozen Iowa communities will be receiv-
ing financial help to recruit medical profes-
sionals, according to information from the
Iowa Department of Public Health.
The grants will go to 12 facilities and will
be used for everything from purchase of
equipment, health assessments, connections
to the fiber optic network and recruitment of
medical professionals. The 12 communities
were chosen from 33 applicants. Eleven
grants are for $10,000; one is for $30,000.
Recipients are:
Van Buren County Hospital, Keosauqua
City of Fonda
City of Lake Park
Massena Industrial Development Corp.
Sloan Community Development Council
Mercy Hospital, Corning
Stacvville Community Nursing Home
Lucas County Memorial Hospital
St. Mary’s, Dyersville
Kossuth Regional Health Center, Algona
City of Maxwell
Pella Community Hospital [EH
The Iowa Medical Society Alliance
Board of Directors and past IMS A
presidents extend best wishes to you
and your family for a happy holiday season!
AMA-ERF Holiday Sharing Card Contributors:
Janice & Robert Bannister
Kathy & Larry Beaty
Barbara & Jim Bell
Dorothy & Fred Carpenter
Ann & Charles Crouch
Tom & Christy DeBartolo
Patti & Jim Dolezal
Cindy & Dean Ehrecke
Lou & Bill Eversmann
Mary Jo & Robert Godwin
Hermina & Philip Habak
Martha & Paul Holzworth
Geni & Dwayne Howard
Kay & Robert Kent
Mary Ellen & Jim Kimball
Joan & Gary LeValley
Maureen & Ken Lyons
Yvonne & Dennis Mallory
Karen & Nick Messamer
Linda & Harold Miller
Elaine Olsen
Carol & Cliff Rask
Mary Jo & David Rater
Ruth & James Reed
Gail & Martin Sands
Jeannine & Bob Schulze
Becky & Koert Smith
Pam & Bob Smits
Sharon & Allan Swanson
478 Iowa Medicine Volume 85 / 12 December 1995
ne
CURRENT ISSUES
Medical Economics
Managed Substance Abuse Care Plan
The Iowa Department of Human Services
recently sent a detailed letter to Iowa physi-
cians regarding the Iowa Managed Substance
Abuse Care Plan (IMSACP).
The letter discusses evaluations, eligibility,
referral and billing for Medicaid patients
receiving substance abuse services.
The informational release was written pri-
marily for health care providers who are not
under contract with IMSACP. Any physician
who has a question about the program may
call the IMSACP provider hotline, 800/836-
8619, during business hours.
The IMS has a copy of the IMSACP infor-
mational release. If you would like one, call
Sherry Johnson at the IMS, 800/747-3070 or
515/223-1401.
AMA: Don’t dilute CLIA reform
The American Medical Association and 16
medical specialty societies were successful in
convincing Congressman Thomas Coburn,
MD (R-OK) to abandon efforts to offer a draft
amendment on CLIA in the House Ways and
Means mark-up on Medicare.
In a strongly worded letter, the AMA urged
Congressman Coburn not to offer his amend-
ment, which would have narrowed the CLIA
reform legislation contained in the House
leadership Medicare reform package, exempt-
ing only labs which “meet requirements of a
recognized quality assurance program for lab-
oratory services”.
According to a recent backgrounder piece
from the Heritage Foundation, physician labs
are “caught in a web of government red tape”
that adds billions of dollars to America’s
health care costs. The Heritage Foundation
supports CLIA reform in the context of
Medicare reform.
“This misguided regulatory intervention is
based on faulty data, has caused the loss of
private laboratory testing and has compro-
mised patient access to high quality care,”
says the informational release.
According to Heritage, CLIA implementa-
tion adds between $1.2 billion and $2.1 bil-
lion annually to the cost of performing clini-
cal lab tests in doctors’ offices.
IICFA officials failed to account for the fol-
lowing cost factors brought about by CLIA:
•Abrupt changes in practice patterns.
•The cost of return visits to have test
results previously available at the time of the
initial visit explained and a treatment regi-
men advanced.
•Unnecessary hospitalizations and emer-
gency room visits when a physician cannot
perform certain tests in the office due to
excessive regulatory costs.
•Increased morbidity and complication
rates from diagnostic delays in notifying
patients of serious problems.
Fortunately, CLIA’s regulatory burdens on
doctors and the impact on patients have
attracted attention in both the House and
Senate. In the House, Bill Archer and dozens
of his colleagues are leading the effort to rein-
troduce sense and sanity to the issue. Kay
Bailey Hutchison and colleagues are sponsor-
ing a similar bill in the Senate.
Any physician who would like copies of the
Heritage Foundation backgrounder on CLIA
may call Chris McMahon or Bev Corron at the
IMS, 800/747-3070 or 515/223-1401. The
piece focuses on the roots of CLIA, CLIA’s
impact on medical practice and the high cost
of regulating without scientific consensus.
Medicalization of social problems
The “medicalization” of social problems
accounts for over one third of America’s
health care costs, according to Leroy
Schwartz, MD, president of Health Policy
International (IIPI).
The US has the highest rates of unsafe sex,
continued
AT A GLANCE
Druggists in growing
numbers are refusing to
sell tobacco products. In
California, they say that
cigarette sales violate
their commitment to
public health; the AMA
has urged local medical
societies to encourage
such actions. Mean-
while, the Canadian
Supreme Court has
struck down the ban on
tobacco advertising, say-
ing it violates free
expression.
•
Though there’s lots of
talk about big savings
that can be accom-
plished by rooting out
waste and fraud and
sharing the money with
whistle-blowers, the sav-
ings won't even match
the 815 billion growth in
Medicare this year, ac-
cording to a recent issue
of Kiplinger Newsletter.
Iowa Medicine Volume 85/ 12 December 1995 479
Iowa|Medicine
CURRENT ISSUES
Medical Economics
continued
Getting sued is a
highly unpleasant
experience, but it
doesn’t have to be
personally
devastating if
you maintain a
calm and
positive outlook.
teenage pregnancy and violence of all the
world’s developed countries. (According to a
recent issue of Kiplinger Newsletter , 30% of
American babies are now born out of wedlock
— up from 18% in 1980. Experts are predict-
ing this illegitimacy rate will have far-reach-
ing effects since these children do worse in
school and are more likely to be violent.)
According to HPI, treating our social prob-
lems accounts for 8225 billion of America’s
S945 billion health care bill.
The chart below is a breakdown of costs
directly associated with social issues.
Health care costs directly
ASSOCIATED WITH SOCIAL PROBLEMS
• Alcohol abuse $50 billion
• Smoking $50 billion
• Poverty $25 — $50 billion
(care for illegal immigrants, delayed
medical care, lack of immunizations)
• Cultural attitudes $33 billion
(heroic measures)
• Unsafe sex $19.4 billion
(AIDS, pelvic inflammatory disease)
• Violence $10 billion
(homicide, assaults, rape, arson)
• Drug abuse $6.7 billion
• Gambling $6 billion
Keep a cool head in face of a lawsuit
Getting sued is a highly unpleasant experi-
ence, but it doesn’t have to be personally dev-
astating if you maintain a calm and positive
outlook. That’s the advice offered in a recent
edition of Minnesota Physician.
Though the case against you may be dated
or frivolous, you are forced to defend it.
Remember that this is what legal profession-
als are for. The legal world is vastly different
from the medical world, so try not to be too
rigid or overly-defensive. It is normal to be
frightened, but acquainting yourself with the
legal process you will have to go through will
make it easier.
Once you have obtained legal advice that
you trust and are comfortable with, try to
focus your life on something else — your
practice, your family, a hobby. If you let a
lawsuit consume your life, you lose — no
matter what the outcome in court.
When your case goes to trial, budget suffi-
cient time for work needed on the case and
time for yourself. Take care of yourself so you
will do your best in the trial.
Finally, remember that you can be totally
in the right and still lose. You can’t necessar-
ily control that. This is why you have mal-
practice insurance.
Employer expectations of HMOs
Only 20% of respondents in a recent survey
listed HMO accreditation by the National
Committee for Quality Assurance as an
important criteria for selecting an HMO.
Access by employees and their dependents
was listed by 72% of respondents as the most
important criteria when selecting HMOs.
Only 8% listed an HMOs ability to provide
IIEDIS reports as an important criteria.
The survey of 196 mid-size to large compa-
nies was conducted by National Underwriter
magazine.
Health care costs below inflation
After a decade in which health care costs
exceeded the inflation rate four times over, a
new study finds that health insurance premi-
um increases have finally begun to fall below
inflation, AM Best reports.
According to the report, employers’ cost at
more than 1,000 medium sized and large
companies rose just 2% from 1994 to 1995,
compared with an overall inflation rate of
2.8%.
The report said the widest disparity
between the inflation rate and premium
increases occurred in 1989, when premiums
shot up 20% and the inflation rate was 5%. El
480 Iowa Medicine Volume 85 / 12 December 1995
Iowa Medicine
CURRENT ISSUES
Practice Management
IMS physicians interested in data
Physicians and their office staff are
extremely interested in learning more about
the roles of data and technology in future
medical practices, according to a recent sur-
vey of IMS members.
The survey, which got a 24% response rate,
produced two major conclusions regarding
the focus of future IMS activities:
•IMS should continue its practice manage-
ment educational activities, striving to pro-
vide “cutting edge” education for members
and their staff.
•IMS should undertake an exploration of
appropriate roles for the IMS in the emerging
areas of data and technology.
The survey results show that the quality of
IMS educational programs is felt to be equal
or higher than that of comparable programs.
According to the survey, 92% of IMS mem-
bers are using computers in their practices
and 89% are submitting insurance claims
electronically. The size of the practice corre-
lates directly with their interest in data —
many larger groups are already using peer
comparison data. Smaller offices (under 20
physicians) said that assisting members with
data should be an IMS priority.
At its November meeting, the IMS Board of
Trustees reviewed the survey results in the
context of the IMS strategic plan.
Medical Business Specialist graduates
Three Medical Business Specialists com-
pleted the requirements for their certificate
during the fall 1995 seminar schedule. They
were presented their plaques at seminars in
September and October.
Lana Slagle, secretary to Dr. Carol Scott-
Conner, head of the UI Department of
Surgery, began the MBS program in May,
1994.
“As an academic administrative secretary
at the U of I Hospitals and Clinics, I do not get
the chance to work with many skills taught in
continued
Midwest Medical Insurance Company • Focus on Risk Management
Patient satisfaction
Do patients perceive you as caring and respectful? Do they feel their problems are as impor-
tant to you as to them? Do they feel they are receiving adequate information from you?
Patient satisfaction has never been more important. Your patients have become educated con-
sumers of health care. They are aware that you are selling a service and that they are buying it.
The focus of the managed care market has also turned toward patient satisfaction. With all this
attention on pleasing patients, their expectations have risen.
Answers to the above questions will help you determine if patients are happy or dissatisfied
with the care you’ve provided. Dissatisfied patients are more likely to sue after a bad outcome. It’s
far better to deal with satisfaction issues up front than to find out about them through a malprac-
tice claim.
To help improve your patient satisfaction:
•Communicate caring through nonverbal gestures, body posture and facial expressions.
Maintain eye contact; sit during conversations.
•Avoid medical jargon. Use the patient’s vocabulary level.
•Use written and audiovisual methods to communicate information.
•Give patients your undivided attention. Try not to interrupt their “story”.
For further information, contact Lori Atkinson, MMIC risk management supervisor. MMIC West Des
Moines office, PO Box 65790, West Des Moines, Iowa 50265, 800/798-9870 or 515/223-1482.
AT A GLANCE
What questions are you
allowed to ask of job
applicants with disabili-
ties? New Equal Emp-
loyment Opportunity
rules let employers ask
applicants who are
obviously disabled
about accommodations
they would need to do a
job. For a free copy of the
guidelines, write to:
Office of Community
Affairs, EEOC, 1801 L
Street NW, Washington,
DC 20507. To order by
phone, call 800/669-
3362 and ask for “ADA
Enforcement Guidance:
Preemployment Disa-
bility Related Questions
and Medical Examin-
ations”.
•
It’s only a matter of time
before you are the target
of marketing by poten-
tial CHMIS networks
wanting you to sign a
contract. Before you do,
read the important
information on page
476 of this issue.
Iowa Medicine Volume 85 / 12 December 1995 481
lowa | Medicine
CURRENT ISSUES
Practice Management
continued
Lana Slagle
Denise Schroeder
Shemain Pirmann
this program, such as coding and billing,” Ms.
Slagle commented. “However, the overview I
received with respect to what is happening in
the private medical office and in various
offices of UIIIC was very educational. I was
able to get the big picture and an appreciation
of how my job fits into the organization. I
enjoyed this Iowa Medical Society program
and hope it continues to expand.”
Denise Schroeder, clinic manager of the
Franklin Medical Center, Inc. in Hampton,
began the MBS program in June, 1994. Ms.
Schroeder makes the following comment
about the experience: “The MBS program
gave me a better understanding and knowl-
edge which has benefited me in my role as
clinic manager.”
Shemain Pirmann is computer supervisor
for Obstetrics & Gynecology Specialists, PC
in Davenport. She began the MBS program in
May, 1994.
“I am pleased to say that I enjoyed being
involved in the MBS program. I gained some
good and helpful knowledge. I strongly rec-
ommend this program for managers and
other staff members.”
Congratulations to these three MBS partic-
ipants. El
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482 Iowa Medicine Volume 85/ 12 December 1995
Iowa | Medicine
CURRENT ISSUES
Newsmakers
Handbook is “comprehensive and impressive”
Dear Editor:
Thank you for permission to reproduce the
“Physicians’ Handbook on Domestic Abuse,”
provided by the Iowa Medical Society. The
handbook and “Break the Silence, Begin the
Cure” video will be used for our second year DO
students in their psychiatry seminar on domes-
tic violence.
For some time I
have been looking for
a comprehensive, edu-
cational program on
domestic violence for
our students. I com-
mend the IMS and Blue
Cross Blue Shield for
this valuable resource. The handbook is com-
prehensive and impressive. The video
incorporates relevant data and necessary dy-
namics for student training.
Please convey my sincere appreciation to all
of the participants of this very fine project. —
Rebecca Monsma, MSW , Department of
Behavioral Medicine and Psychiatry, Univer-
sity of Osteopathic Medicine and Health
Sciences, Des Moines
Awards, appointments, etc.
Dr. Alan Bollinger. Des Moines, has been
appointed director of emergency medicine ser-
vices at Broadlawns Medical Center. Dr. Michael
Sparacino has been named the program direc-
tor for Family Practice Residency at North Iowa
Mercy Health Center in Mason City. Dr. Kory
Kazarian, family physician, has joined the Cov-
enant Clinic in Cedar Falls. Dr. Greg Ilalbur,
family practice, has joined Midtown Medical
Clinic in Sioux City. Two new clinical depart-
ment heads have been appointed at the UI
College of Medicine: Dr. Evan Kligman will
direct the Department of Family Practice and
Dr. Carol Scott-Conner will head the Depart-
ment of Surgery. Dr. Kligman succeeds Dr.
Letter
to the
Editor
Gerald Jogerst who has served as interim head
of the department since June 1994. Dr. Scott-
Conner succeeds Dr. Robert Soper who has
served as interim head since 1992. Dr. Scott
Aigner has joined Dubuque Urology. Dr. Patrick
Sterrett has joined Dr. David Field in medical
practice in Dubuque. Dr. Robert Burke, gen-
eral surgeon, has retired after 36 years of prac-
tice in Jefferson. Dr. Meredith Saunders has
joined Physicians Eye Clinic in West Des Moines.
Dr. Axel Lund and Dr. John Reinertson of
Marshalltown Family Medical Services have
joined McFarland Clinic in providing services
to the Marshalltown area. Dr. James Collins,
Waterloo, has been appointed to represent the
Federation of State Medical Boards on the Ac-
creditation Review Committee of the Accredi-
tation Council for Continuing Medical Educa-
tion. Dr. Collins is chairman of the Iowa Board
of Medical Examiners. Dr. Arthur Devine, urol-
ogy, received the Thirlby Award as the practic-
ing member judged to have given the best
scientific presentation at the annual meeting of
the North Central Section of the Americn Uro-
logic Association. Dr. John Wollner, Cedar
Rapids internist, has been named chairman of
the comprehensive school health education
committee of the American Cancer Society,
Linn County Unit. Dr. Donald Young, profes-
sor in the Department of Radiology, UI College
of Medicine and a member of the AMA’s Council
on Scientific Affairs, has been appointed chair-
man of the Diagnostic and Therapeutic Tech-
nology Assessment Committee of that Council.
Dr. Jerome Gleich of Ottumwa Regional Health
Center, has been awarded status as a diplomate
board certified forensic examiner of the Ameri-
can Board of Forensic Examiners.
Deceased members
Harry Alcorn, MD, 75, ophthalmology, Clear
Lake, died April 4
Lancelot Eller, MD, 87, life member, family
practice, Richland Center, Wisconsin, died
August 7 HU
AT A GLANCE
Dr. Paul Seebohm, emeri-
tus professor at the UI
College of Medicine, Iowa
City, was recently hon-
ored at a dedication of a
conference room named
in his honor.
Mercy Hospital Medical
Center, Des Moines has
been recognized as a
Level II Trauma Center
by the American College
of Surgeons Committee
on T rautna. The verifica-
tion makes Mercy one of
fewer than 60 hospitals
nationwide to receive this
stamp of approval and
only the second Ameri-
can College of Surgeons
verified trauma center in
Iowa.
Iowa Medicine Volume 85 / 12 December 1995 483
Iowa | Medicine
FEATURE ARTICLE
self-referral law
Steves Beck, JD
Mr. Beck is chair of the
firm's health law depart-
ment. His practice focuses
on advising physicians,
hospitals and payers on
health care integration
and joint ventures.
David Glaser, JD
Mr. Glaser is a member of
the firm’s health law group.
The focus of his practice is
health care regulation,
including regulatory
compliance and appeals.
The authors practice with the
firm of:
Fredrikson & Byron
900 Second Avenue South
Minneapolis, MN 55402
612/347-7000
Should Iowa physicians worry about the Stark law? Probably.
In September, after a nearly four-year delay, the regulations
for Stark I took effect. This article discusses how the Stark I
and II self-referral laws might affect your practice.
In the last few years, Congress passed two
self-referral laws, commonly referred to as
Stark I and II. Because Stark I involved
referrals for laboratory services, the
regulations do not answer all of the questions
about the other designated health services
covered by Stark II. Several proposals have
been introduced in Congress to scale back
the Stark law.
Law has broad reach
The Stark law has a very broad reach; if
you haven’t considered the law’s impact, one
of its provisions is likely being violated in
your practice. The penalties for a violation
are severe — up to SI 5, 000 per claim
submitted to Medicare or Medicaid
and exclusion from the Medicare
program.
Stark is not an intent-based
rule. The government does not
need to prove that your medical
judgment was affected by the
financial arrangement. If you have
any compensation arrangement
that violates the law, you may be
fined $15,000 for each claim you submit to
Medicaid or Medicare. The law is very
complex and this article focuses on six of the
most commonly-asked Stark questions.
1
What does Stark prohibit?
Stark prohibits a physician from
“referring” a Medicare or Medicaid patient to
any clinic or entity for one of 11 “designated
health services” if the physician has
ownership interest in the entity (through
equity or debt) or receives any compensation
for it. Compensation is defined quite broadly.
If a physician receives cash or services from
an entity, it is considered compensation.
2
What is a “referral”?
The law defines referral quite
broadly, including many situa-
tions that most physicians would
not consider a referral. With a few
exceptions, the law says that
whenever a physician develops a
plan of care for a service, the
The government
does not need to
prove your medical
judgment was
affected by the
financial
arrangement.
484 Iowa Medicine Volume 85 / 12 December 1995
FEATURE ARTICLE
physician has made a referral. As a result, if
you recommend physical therapy to a
patient you have made a referral for a
designated service, even if you do not tell the
patient where to receive care. If money
changes hands between you and the
therapist selected by the patient — either
through a lease or any other arrangement —
Stark is implicated.
3
What are designated health services?
The following services are considered
“designated health services”:
•clinical laboratory services
•physical therapy
•occupational therapy
•radiology or other diagnostic services
•radiation therapy services
•durable medical equipment
•parenteral and enteral nutrients
•equipment and supplies
•prosthetics
•orthotics and prosthetic devices
•home health services
•outpatient prescription drugs
•inpatient /outpatient hospital services
The law does not further define these
terms and, in some cases, it is difficult to
discern the legislators’ intent. For example,
“outpatient prescription drugs” would appear
to cover only prescriptions to hospital
patients. However, until final regulations
governing Stark II are published or the law is
repealed, these terms will remain ambiguous.
Remember, only Stark I regulations have
been issued at this time. These cover clinical
laboratory services.
4
What are the exceptions?
Exceptions to the law fall into three broad
categories. Some apply to compensation
arrangements, some apply to ownership or
investment interests and some apply to both.
Ownership and compensation arrangements
The most powerful exception applies to
most in-office ancillary services other than
I)ME or parenteral and enteral nutrition. In-
office ancillary services must be provided
within a group practice and directly
supervised by a physician. (Direct
supervision requires a physician to be able to
reach the area within about 30 seconds.)
The key term is “group practice”. To
qualify, no portion of a group’s compensation
system may be “based on the volume or value
of referrals”. While it is possible to include a
physician’s personal production in a clinic
compensation formula, Stark prohibits clinics
from crediting physicians with the value of
referrals for ancillary services.
Any practice that has a physician who
provides services to another practice must be
particularly careful. Whenever a practice bills
for services rendered by a physician, that
physician is considered part of the group
practice.
The regulations require that 75% of the
The law prohibits
clinics from
crediting physicians
with the value of
referrals for
ancillary services.
Iowa Medicine Volume 85 / 12 December 1995 485
Iowa I Medicine
FEATURE ARTICLE
continued
Regulations require
that 75% of the
professional
services provided
by members of the
group must be
billed by the group.
professional services provided by members of
the group must be billed by the group. Small
groups that bill for the services of a physician
who spends time at another practice may
have difficulty meeting this standard.
For example, assume that two members of
a practice spend 100% of their time at a
clinic, while the third physician spends 10%
and the remainder of his practice is
elsewhere. Using the formula in the
regulations, only 70% of the aggregate
services provided by the physicians are
provided through the group. As a result they
would not qualify as a “group practice”.
Ownership interest exceptions
Providers who practice in a rural area are
covered by an exception which allows them
to have an ownership interest in a designated
health service. To qualify, 75% of the clinic’s
patients must live outside of an urban area.
In Iowa, the following counties are
Designated health services under
Stark law:
•clinical laboratory services
•physical therapy
•occupational therapy
•radiology or other diagnostic services
•radiation therapy
•durable medical equipment
•parenteral and enteral nutrients
•equipment and supplies
•prosthetics
•orthotics and prosthetic devices
•home health services
•outpatient prescription drugs
•inpatient and outpatient hospital service
considered urban: Black Hawk, Dubuque,
Woodbury, Pottawattamie, Linn, Scott, Dallas,
Polk, Warren and Johnson. Of course, a rural
practice must still design its compensation
system to comply with Stark. Lah and other
ancillary services must be excluded from the
compensation formula.
Another exception allows ownership in
large, publicly traded companies. The
company must have total assets of at least
$75 million.
The third exception allows a physician to
own part of a hospital if the physician
provides services at the hospital and the
ownership interest is in the entire hospital,
not merely a subdivision.
Exceptions to compensation arrangements
A lease of office space or equipment
qualifies for an exception if the lease is
written, runs for one year and contains a
“reasonable” rental payment set in advance
in some manner that does not take into
account the value or volume of any referrals
or other business generated between the
parties. In addition, the space or equipment
must be used exclusively by the lessee during
the relevant period.
As a result, it is improper to lease a room
or equipment on an “as needed” basis. The
lease must define specific hours of use.
A bona fide employment relationship
qualifies for an exception if the services are
identified in a contract and payment is
consistent with fair market value and does
486 Iowa Medicine Volume 85 / 12 December 1995
FEATURE ARTICLE
not take into account the value or volume of
referrals (including referrals for designated
services within a group practice). The
agreement must he considered commercially
reasonable when viewed as if no referral
relationship existed.
The personal service exception permits an
entity to contract with a physician. The
contract must be for at least one year,
describe all of the services to be performed
and serve a legitimate business purpose.
Compensation must be set in advance and
may not take into account the value or
volume of referrals.
5
Does Stark affect me if I sell my
PRACTICE?
Yes. If you will be referring patients for
designated health services to the entity
which purposes your practice, the sale of the
practice must be paid in one lump sum.
Also, any compensation paid to you will
have to satisfy one of the exceptions under
Stark.
6
What is the reporting requirement
under Stark?
There are two reporting requirements in
the law:
• Every group practice must complete a
form designed by IICFA. The regulations
state that the form must be completed by
December 12, 1995. However, since the form
has not yet been designed, some IICFA
officials have indicated the deadline will be
extended.
This attestation is significant because the
government will argue that any group which
completes the form but fails to comply with
every element of the group practice
definition has been submitting false claims.
Under the False Claims Act, both the
federal government and private citizens may
have the right to file suit against providers
who have filed an incorrect attestation. In
some circumstances the private citizen may
be eligible to claim up to 30% of any
recovery.
Since the False Claims Act may result in
penalties of $5,000 — $10,000 per claim, it
provides a strong incentive for both federal
regulators and private citizens to actively
seek violators of the law.
• All entities that provide designated
health services must provide information
about every physician with a financial
relationship to the entity. Medicare carriers
will develop this form and send it to
providers in the near future. Failing to
complete the form can result in a fine of
$10,000 per day.
Stark is a complicated law. Unless it is
entirely repealed, all providers must consider
whether they are in complete compliance. If
you have questions about Stark law and your
own practice, contact an attorney who
specializes in health care issues. Du]
Unless Stark is
entirely repealed,
all providers must
consider whether
they are in
compliance.
Iowa Medicine Volume 85 / 12 December 1995 487
Occupational Medicine
Des Moines, Iowa
(Career Practice Opportunity)
OccuSystems, Inc. is the largest national occupational health care
practice management company in the U.S. today. We are currently
seeking a primary care physician for our occupational health center
in Des Moines, Iowa.
Occupational medicine experience is desirable but not required . We
offer regular work hours with a limited rotating call. In addition, we
guarantee an excellent starting salary along with a year-end bonus
program. Plus progressive future growth and a comprehensive corpo-
rate fringe benefit program . The chosen candidate will assist in the
development of the Des Moines, Iowa market.
If you are interested or would like additional information on this or
other opportunities, call Jeff Moffett, C.M.S.R. or Matt Mearat 1-800-
345-9958 or send your CV to:
Recruiting Dept.
OccuSystems, Inc.
3010 LBJ Freeway, Suite 400
Dallas, Texas 75234
OccuSystems, Inc.
Innovative solutions
for occupational healthcare
Attention IMS Emeritus
and Life Members
Recently you received a letter re-
garding Iowa Medicine magazine.
A postcard was enclosed which must
be returned no later than Decem-
ber 20 if you wish to continue re-
ceiving the journal. If you haven’t
received the letter and postcard and
want to remain on our mailing list,
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or 515/223-1401 (ask for Jane
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OccuSystems, Inc. is an equal opportunity employer.
^/mercyheTlth center Emergency Medicine Opportunity
MASON CITY, IOWA
North Iowa Mercy Health Center (NIMHC), Mason City, Iowa, is a private, not-for-profit, 350-bed medical
center that services a 14+ county region in north central Iowa. For most of a century, NIMHC has combined the
most advanced technology with compassionate care to provide our region with quality medical services.
We are seeking a BC/BP primary care physician with emergency medicine experience or an emergency
trained physician for a full-time position in our facility. We invite you to become a part of our 4-member team in
a modern ED with 23,000 annual visits and weekend double coverage. This position offers competitive compen-
sation and an exceptional benefit package.
Mason City represents the best of the Midwest. It has quiet, tree-lined streets in modem neighborhoods and
radiates that storybook "hometown" feeling. An incomparable lifestyle can be derived from the matchless public
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We would welcome the chance to discuss how this opportunity can fulfill both your professional and
personal needs. For more information, please contact:
Laura Weis, Representative
North Iowa Mercy Health Center • c/o Mercy Health Services
4500 Westown Parkway, Suite 250 • West Des Moines, Iowa 50266
515/224-3260; 515/224-3546 (fax)
Iowa I Medicine
S C I E N C E AND EDUCATION
The Journal
of the Iowa Medical Society
Prostate cancer management in older patients
# William See, MD
Prostate cancer is the most commonly diag-
nosed malignancy among Iowa men. A recent
report by the National Cancer Institute Sur-
veillance Epidemiology and End Result Pro-
gram (SEER) suggests that in Iowa, as well as
other sites across the country, the use of rad-
ical prostatectomy as definitive therapy for
this malignancy has increased dramatically
in the last decade.1 Furthermore, data from
this study suggests that the use of radical
prostatectomy has seen its greatest increase
in patients 70 years and older. From 1991 to
1994 the proportion of men with prostate
cancer 70 years of age and older who
received radical prostatectomy increased
from 4% to 16.9%
The controversy regarding the optimal
management of prostate cancer, both in gen-
eral and for elderly patients in particular,
remains heated. : Indeed, conflicting litera-
ture can be used to support almost any
approach to the treatment of this enigmatic
neoplasm.
In an effort to define the patterns of care
of prostate cancer in the state of Iowa, partic-
ularly as they relate to age at the time of
treatment, a multidisciplinary group was
formed to study patterns of care. The follow-
ing report summarizes the methods, findings
and conclusions of that group.
Materials and methods
At the prompting of Iowa’s state health
care quality assurance group (Iowa Founda-
tion for Medical Care, IFMG), an interdiscipli-
nary group of health care professionals,
including urologists and medical and radia-
tion oncologists, was formed to consider
prostate cancer care delivery issues. After a
review of preliminary data, the group focused
on variations in care delivery for prostate
cancer patients as a function of age.
Data collected from every Iowa hospital by
the staff of IFMG included institution-specific
numbers of radical prostatectomies per-
formed per year and the number performed
in patients 75 years of age and older. Subse-
quently, six institutions were selected for
more detailed review. Of these six institu-
tions, five were in the top five institutions
with respect to those performing the greatest
number of radical prostatectomies per year.
A chart review was performed on the 25
oldest patients undergoing radical retropubic
prostatectomy in the last year at each of the
six institutions. Patient comorbidity was esti-
mated by the incidence of concomitant dis-
ease processes, including coronary artery dis-
ease, chronic pulmonary disease, dementia,
diabetes mellitus, deep vein thrombosis,
renal insufficiency or cerebral vascular dis-
ease. An additional estimate of overall patient
health was obtained from the anesthesia
record documenting anesthesia risk class.
Treatment outcomes were estimated based
upon acute surgical morbidity and pathologic
stage of the patient following the radical
prostatectomy. Outcomes among the six
institutions were then compared.
Results
The proportion of cases 75 years of age or
older showed no correlation between number
of prostatectomies performed, institution size
or size of the city population served. Absolute
percentages among the 13 institutions varied
from 0% to 20% of the total number of prosta-
tectomies performed.
The findings from the detailed subset
analysis of six institutions are summarized in
The IMS
Education Fund
has designated
this article as
the Henry > Albert
Scientific
Presentation
Award for
December 1 995.
William See, MD
Dr. See is associated with
the Department of
Urology, UI College of
Medicine, Iowa City and
the Iowa Prostate Cancer
Cooperative Project.
Other contributing
authors: Robert Dreicer,
MD; Dennis Boatman,
MD; David Hussey, MD;
Leo Milleman, MD; Paul
Rohlf MD; Steven
Rosenberg, MD;
Markham Anderson, MD;
A. Curtis Hass, AID;
Andrea McGuire, MD;
Roscoe Morton, MD; Pat
Ouverson, RN; Merle
Wilson, EdD; Marilyn
Schulte, RN and Timothy
Kresowik, MD.
Iowa Medicine Volume 85 / 12 December 1995 489
Iowa [Medicine
Prostate cancer management in older patients
continued
Table 1. Institutional caseload-percentages
for men 75 years of age and older varied from
2.3% to 20%. Age distributions for the oldest
25 cases among the six hospitals ranged from
4% to 100% age 75 or older. However, rates of
presurgical comorbidity, acute postsurgical
morbidity and final pathologic stage among
the six institutions were comparable.
TABLE 1
RESULTS OF ANALYSIS OF THE 25 OLDEST
PATIENTS UNDERGOING RADICAL
PROSTATECTOMY AT SIX IOWA HOSPITALS
Facility
1
2
3
4
5
6
# of radical
prostatectomies
performed
81
24
70
106
150
42
% >75 years
% of oldest 25
2.5
20.8
4.3
12.3
14.0
4.8
patients aged >75
% of oldest 25
4
20
12
52
100
16
patients w/>l
comorbid condition
8
0
0
8
8
28
total # comorbid
condition
12
11
8
13
11
20
mean ASA class
2.15
1.92
2.17
2.25
2.29 2.00
% postop
complications
4
4
8
0
4
4
% stage C
24
28
20
28
12
36
Discussion
The management of carcinoma of the
prostate is an area of current controversy.
Despite an abundance of opinion, there is
insufficient data to definitively support any
conclusion regarding who should he treated,
by what modality and when. Given the wide
variation in the available literature, virtually
any approach can be justified if literature is
selectively interpreted. The current statewide
review of prostate cancer patterns of care was
undertaken in an effort to determine whether
there were wide variations in patterns of care
within Iowa. Given the recently documented
dramatic increase in the use of radical prosta-
tectomy as curative therapy and particularly
its growth as primary therapy among men 70
years of age and older, the group decided to
focus the efforts of the current review on pat-
terns of care as a function of age. While the
group recognized that many other issues mer-
it consideration, the age-adjusted use of radi-
cal prostatectomy seemed timely and signifi-
cant.
Despite variations in the age distribution of
men treated by radical prostatectomy at vari-
ous institutions, presurgical comorbidity and
acute postoperative morbidity among the old-
est group of patients at each institution
appeared quite comparable. Chronological age
appears to be but one of multiple factors con-
sidered in determining candidacy. The overall
low rate of postoperative complications and
the absence of operative mortality among
these elderly patients speaks to the surgical
judgment and skill of physicians performing
radical prostatectomies in Iowa. Finally, com-
parable postoperative pathologic states sug-
gest that prostate cancer in select men age 75
and older is as potentially curable by radical
prostatectomy as that of men in younger age
groups.
Findings from this limited study suggest
that, in Iowa, relatively uniform criteria are
being used to select patients for radical
prostatectomy, irrespective of patient age.
Careful patient selection, both in terms of the
ability to tolerate the operation and the
potential of the individual patient to see sur-
vival benefit from the procedure, remains the
cornerstone of good patient care.
References
1 . Harlan, L, et al: Geographic, age, and racial varia-
tion in the treatment of local/regional carcinoma of the
prostate. J Clin Oncol 1995;13:93-100.
2. See, WA: Prostate cancer therapy: a recipe for con-
fusion. Iowa Med 1994;255-58.
490 Iowa Medicine Volume 85/ 12 December 1995
Iowa | Medicine
THE EDITOR COMMENTS
A gift to your
grandchildren
Consider an apple core. Compartments of
little brown seeds provide a marvel of
nature; one seed may mature to a fruit-
bearing tree. Ponder the bushels of delicious
apples the tree will provide year after year.
All from one small seed.
There are seeds we can plant for our chil-
dren and grandchildren that will give them a
more satisfying life. One attribute we can
promote is one that is sadly lacking in pre-
sent day education. The youth of today lack
the ability to transform words into thought
processes, both in spoken language and espe-
cially in writing. Educators aver that there is
too little time in the curricula to teach writ-
ing. Nancy Cole, president of the Educational
Testing Service, the organization that admin-
isters SAT and other tests, says
teachers do not have enough time
to teach writing. Writing is no
longer considered a school subject.
She adds that it is too time con-
suming to grade written papers.
It appears it is up to the parents
to stimulate children to become
better writers. There are many
things we can do to help. Reading and writing
are closely intertwined; consequently, it is
incumbent upon us to encourage reading as
well. That can become a simple task. Write
notes and letters to the children, hopefully
encouraging them to answer in writing. It has
become too easy to communicate orally.
The October 1995 issue of Better Homes
and Gardens has an excellent short article
entitled “The Write Stuff”. The author dis-
cusses how to encourage people to write
more. Some of the methods discussed
include such simple tasks as helping to com-
pose the grocery list to more complicated
adventures in learning such as writing a brief
review of something learned from reading a
book or even an encyclopedia. Another area
is encouraging the child to keep a journal, or
writing bits of family history gleaned from
interviews with family members.
As part of your holiday giving, write letters
to the children and the grandchildren instead
of relying upon AT&T, MCI or Sprint. For the
younger ones, printing the letter would be
more appropriate. To encourage handwriting,
the typewriter should be discouraged. The
children’s written responses will
be valuable additions to the refrig-
erator door and can be kept for
future enjoyment. That future
enjoyment will be fun for the
child as well as comparisons can
be made of the progress of the
writing skills.
There is no question the child
will profit from your writing, and your enjoy-
ment of their letters and notes will be an
immeasurable gift of love from them. O
Iowa Medicine Volume 85 /
Write letters
to the
grandchildren
instead of
relying upon
AT&T.
Marios Alberts, MD
12 December 1995 491
BlueCross BlueShield
of Iowa
Provider Service Center:
Statewide: 800-362-2218
Des Moines: 515-245-4688
Iowa 1 Medicine
PHYSICIAN LEARNER
Learning from our
legal colleagues
Note: This is the final article in a three-
part series on interdisciplinary CME.
Being the student of a mentor within the
same medical discipline, or learning
from a colleague in another health care
profession are accepted educational modes
among physicians. Learning from persons
less directly engaged in health care may be
another matter for doctors. Some physicians
question the need or value of such learning.
Yet the practice of medicine exposes
physicians to a broad spectrum of societal
issues and values, each with a learned con-
stituency. Contemporary health care is hard-
ly conceivable without interactions with pub-
lic officials, health care financing managers,
the clergy, attorneys and others.
There may be no group about
which physicians have more ambi-
valent convictions than attorneys.
In the collective mind of the med-
ical profession lawyers are either
leading the assault against reason
and common sense in the care of
patients, or they are the last bas-
tion of defense against the insatiable public
demand for error-free medical care.
Attornevs, as heterogeneous a professional
group as physicians, represent a spectrum of
influences on medical practice and have had
a profound impact on the delivery of health
care. That impact is not necessarily onerous.
A convincing case might be developed that
demonstrates how attorneys and the law
have enlightened the profession.
Two examples may suffice for illustration.
The first is the development of the practice
of informed consent. Most consumers (or
their advocates) would characterize informed
consent as a means to protect patients from
unwarranted risk without adequate benefit.
Physicians might well view the practice of
informed consent as the protection of the
physician from unwarranted expectation
without understanding of risk. Informed con-
sent should serve both functions. Our attor-
ney colleagues have protected each party in
the health care transaction through informed
consent.
The second illustration may be more con-
troversial. Attorneys assist physicians in
maintaining the quality of prac-
tice by litigating cases which
question medical competence.
While physicians may rail against
the abuses inherent in many such
procedures, there is no doubt that
some persons have been harmed
by their physicians’ acts or negli-
gence. We strive for preventive
peer review, but the potential of legal redress
frames the issue. As physicians and con-
sumers, we would not want a system without
such protection.
Learning from attorneys may not have
been an expectation of physicians when they
embarked on their careers, but we should be
open to the unanticipated. [Q
There may be no
group about which
physicians have
more ambivalent
convictions than
attorneys.
Richard Nelson, MD
Iowa Medicine Volume 85 / 12 December 1995 493
I owa [Medicine
Index to Volume LXXXV
Numbers 1-12 (1995)
Agarwal, RK, MD, and A Al-Shash, MD, Latex
allergy 289
Air pellet gun injury, Daniel Waters, DO, ef al 331
Al-Shash, A, and RK Agarwal, MD, Latex allergy 289
Alzheimer’s disease: the role of tacrine therapy,
Gerald Jogerst, MD 409
AMA scores liability victory in House, Robert
McAfee, MD 197
Antibiotic resistance: an emergency we can’t ignore,
Stephen Rindernecht, DO 127
Apnea and vomiting in an infant due to cocaine
exposure, Enehomere Okoruwa, et al 449
Beck, Steven, JD and David Glaser, JD, Stark
self-referral law 484
Bell, Barbara, A mass media reality check 11
Bergus, George, MD and Steven Meis, MD, Hepatitis
B vaccination: a cost analysis 209
Bilgi, Jagadish, MD, et al, Duodenal web with
preduodenal portal vein 247
Bower, Warren, MD, et al, Laparoscopic
splenectomy 87
Broghammer, Benjamin, MD, et al, Air pellet
gun injury 331
Break the silence, begin the cure 21
Briggs, Terrence, MD, IMS staying involved
in the GHMIS process 317
Brinkman, Maxine, North Iowa responds
to domestic violence 57
Buekwalter, Kathleen, RN and Lee Fagre, MD,
Iowa domestic abuse scenarios 85
Cancer in Iowa, 1995 120A
CHMIS Update 235, 277, 355, 395, 437, 476
Chell, Dale, Who are the batterers? 28
Child’s perspective on abuse of a parent, by a
parent, A, Donner Dewdney, MD 33
Clark, Christine, A survivor’s story 26
CME Seminars 330, 408, 448
Coster, David, MD, et al, Laparoscopic
splenectomy 87
Deadline news 3, 51, 103, 187, 227,
267, 307, 347, 387, 427, 467
Death, dying and Iowa law, Becky Roorda 284
DeNelsky, Steve, Financing of physician ventures 202
Densen, Peter, MD, A new course for
medical education 164
Dewdney, Donner, MD, A child’s perspective on
abuse of a parent, by a parent 33
DiBaise, John, MD, Thyrotoxic periodic paralysis 291
Documenting domestic abuse, Curtis Ruby 76
Dolphin, Susan, MSW, et al, Service delivery to persons
with HIV and AIDS 250
Domestic violence programs 80
Domestic violence: the law and physician
liability, Jeanine Freeman, JD 70
Dordick, Vera, The future of vaccines 166
Dorner, Ralph, MD, Physicians on the front line 324
494 Iowa Medicine Volume 85/ 12 December 1995
Duff, Mark, MD, et al. Air pellet gun injury 331
Duodenal web with preduodenal portal vein, Sergio
.247
.443
.250
.85
.484
.247
.446
Golombek, MD, et al
E & M coding ... is Iowa complying with I1CFA
guidelines?, John Olds, MD and Kent Moss, MD
Engebretsen, Bery, MD, et al. Service delivery
to persons with HIV and AIDS
Fagre, Lee, MD and Kathleen Buekwalter, RN,
Iowa domestic abuse scenarios
Farewell to a friend 473
Fick, Daniel, MD, and David Tearse, MD, Sports
medicine education in in the U.S 171
Financing of physician ventures, Steve DeNelsky 202
Finding the right words 22
Freeman, Jeanine, JD, Domestic violence: the law
and physician liabilities 70
Future of vaccines. The, Vera Dordick 166
Futures 13, 60, 113, 150, 194,
234, 276, 315, 354, 394, 436, 475
Ganske, Greg, Greg Ganske on Medicare reform 446
Gerdes, Karen, MD, et al. Apnea and vomiting in an
infant due to cocaine exposure 449
Give the gift of hope, Robert McAfee, MD 9
Glaser, David, JD and Steven Beck, JD, Stark
self-referral law
Golombek, Sergio, MD, et al, Duodenal web with
preduodenal portal vein
Greg Ganske on Medicare reform, Greg
Ganske, MD
Hall, Joseph, MD, The right to privacy vs the
public’s right to know
Hepatitis B vaccination: a cost analysis, George
Bergus, MD and Steven Meis, MD 209
Here’s to Your Health, Domestic abuse, 74A; Organ &
tissue donation, 284A
Hess, John, MD, Physicians on the front line 324
Index to Volume LXXXV 494
IMS House of Delegates proceedings 294A
IMS, Iowa physicians focus on CHMIS, Sterling
Laaveg, MD 242
IMS staying involved in the CHMIS process,
Terrance Briggs, MD 317
IMS Update 12, 58, 1 12, 148, 192,
232, 274, 314, 352, 392, 434, 474
Iowa CHMIS Questions and Answers 326A
Iowa domestic abuse scenarios, Lee Fagre, MD and
Kathleen Buekwalter, RN 85
Iowa physicians and community hospitals . . . bound
by common interests, Cooper Parker 404
Jogerst, Gerald, MD, Alzheimer’s disease: the role
of tacrine therapy 409
Kelch, Robert, MD, UI College of Medicine in the
21st century 161
King Will and the Foul Humours: a fable for reform,
Robert McAfee, MD 109 |
Krypel, Robert, JD, Pitfalls of integration 122
.432
INDEX
Laaveg, Sterling, MD, IMS, Iowa physicians focus on
CHMIS 242
Laparoscopic splenectomy, Warren Bower,
MD, et al 87
Latex allergy, RK Agarwal, MD and A
Al-Shash, MD 289
Legislative Affairs 14, 62, 115, 152, 196,
236, 278, 318, 356, 396, 438, 477
Leigh, Darcy, DO and Subhash Sahai, MD,
Metastasis of adenocarcinoma of breast to
gluteus medius 369
Maher-Sharp, Kay, Why do they stay? 24
Managed care in Iowa, a difficult transition, Christine
McMahon 364
Mass media reality check, A, Barbara Bell 11
McAfee, Robert, MD, AMA scores liability victory
in House 197
McAfee, Robert, MD, Give the gift of hope 9
McAfee, Robert, MD, King Will and the Foul Humours:
a fable for reform 109
McMahon, Christine, Managed care in Iowa, a difficult
transition 364
McMahon, Christine, Physicians on the
frontline 324
Medical Economics 15, 64, 117, 154, 198,
238, 279, 320, 358, 398, 440, 479
Meis, Steven, MD and George Bergus, Hepatitis B
vaccination: a cost analysis 209
Metastasis of adenocarcinoma of breast to gluteus
medius, Subhash Sahai, MD and Darcy
Leigh, DO 369
Moss, Kent, MD and John Olds, MD, E & M coding
... is Iowa complying with HCFA guidelines? 443
Myths and realities 83
New course for medical education, A, Peter
Densen, MD 164
Newsmakers 19, 68, 121, 158, 201,
241, 282, 322, 362, 402, 442, 483
North Iowa responds to domestic violence,
Maxine Brinkman 57
Okoruwa, Enehomere, MD, et al, Apnea and
vomiting in an infant due to cocaine exposure 449
Olds, John, MD and Kent Moss, MD, E & M coding . . .
is Iowa complying with HCFA guidelines? 443
Ordona, Truce, MD, Understanding domestic
violence 35
Organized medicine: it’s for students, too,
Eric Stone 313
Parker, Cooper, Iowa physicians and community
hospitals . . . bound by common interests 404
Physician Learner, Richard Nelson, MD, The
continuum of medical education, 91; Retraining
physicians for primary care, 175; The advancement
of practice, 255; When physicians learn from
colleagues, 335; Learning in a health care team, 415;
Learning from our legal colleagues, 493
Physicians on the front line,
Christine McMahon 324
Pitfalls of integration, Robert Krypel, Jl) 122
Practice Management 17,66, 119, 156, 200, 239,
281, 321, 360, 400, 481
Prostate cancer management in older patients,
William See, MD 489
Referral information 80
Rindernecht, Stephen, DO, Antibiotic resistance: an
emergency we can’t ignore 127
Right to privacy vs the public’s right to know,
The, Joseph Hall, MD 432
Roorda, Becky, Death, dying and Iowa law 284
Ruby, Curtis, Documenting domestic abuse 76
Rural battered women, Laurie Schipper 78
Schipper, Laurie, Rural battered women 78
Sahai, Subhash, MD and Darcy Leigh, DO,
Metastasis of adenocarcinoma of breast to
gluteus medius 369
Saunders, Edward, PhD, et al, Service delivery
to persons with IIIV and AIDS 250
See, William, MD, Prostate cancer management
in older patients 489
Seebohm, Paul, MD, Your help is needed! 273
Service delivery to persons with HIV and AIDS,
Edward Saunders, PhD, et al 250
Shah, Rizwan, MD, et al, Apnea and vomiting in
an infant due to cocaine exposure 449
Sports medicine education in the US, Daniel
Kick. MD and David Tearse, MD 171
Stark self-referral law, Steven Beck, JD and
David Glaser, JD 484
Stickler, Robert, MD, Physicians on the
front line 324
Stone, Eric, Organized medicine: it’s for
students, too 313
Survivor’s story, A, Christine Clark 26
Tearse, David, MD and Daniel Fick, MD, Sports
medicine education in the US 171
The Art of Medicine, Richard Caplan, MD, Healing
diversions, 39; Inflict kindness, 131; Reading fast
. . . now . . . slow, 215; What’s in a name?, 295;
Remembering, 375; Gullibility, 455
The Editor Comments, Marion Alberts, MD, A world
of violence, 37; Family life can be beautiful, 89; What a
difference a generation makes, 129; As life passes by,
173; Why are so many people depressed?, 213;
Oath of Hippocrates still valid, 253; Are you afraid of
death?, 293; Looking back and finding change, 333;
Drive-thru delivery, 373; A letter to your spouse, 413;
Have I been a good parent?, 453; A gift to your
grandchildren, 491
The President Comments, Watch for red flags, 7; The
AMA in action, 55; Exciting times, 107; Helping
our patients and our communities, 147; Farewell
advice, 191; Why we need to organize, 231; Three
important issues, 271; Principles of Medicare
reform, 311; The corporatization of health care,
351; Why I belong, 391; PACs are a reality, 431;
AMA’s role in the Medicare reform bill, 471
Thyrotoxic periodic paralysis, John DiBaise, MD 291
Ukabiala, Oneybuchi, MD, et al, Duodenal web with
preduodenal portal vein 247
UI College of Medicine in the 21st century,
Robert Kelch, MD 161
Understanding domestic violence, Truce
Ordona, MD 35
Waters, Daniel, DO, et al, Air pellet gun injury 331
Westberg, Mark, MD, et al, Laparoscopic
splenectomy 87
What works, what doesn’t 82
Who are the batterers?, Dale Chell 28
Why do they stay?, Kay Maher-Sharp 24
Wilson, Victor, MD, et al, Laparoscopic
splenectomy 87
Your help is needed!, Paul Seebohm, MD 273
Iowa Medicine Volume 85/ 12 December 1995 4 95
Iowa [Medicine
Classified Advertising
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tioners to join multispecialty group with 165
providers and 14 clinics located throughout
the metropolitan area. Thriving blend of fee-
for-service and managed care patients;
governed and managed by its own health care
providers; guaranteed based salarv+, excellent
benefits. Send CV to Nancy Borgstrom, Aspen
Medical Group, 1021 Bandana Boulevard E
#200, St. Paul, Minnesota 55108, 612/642-
2779 or fax 612/642-9441. EOE.
S3
£
Marshalltown Medical
& Surgical Center
Seeking quality primary care
trained or emergency medicine
physician to practice at MMSC.
• Stellar EM practice
• Full-time, regular part-time and
moonlighting opportunities
• 14K annual volume
• 12-hour shifts, 24-hours/7day
coverage
• Excellent benefit/bonus packages
• Paid St. Paul malpractice
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE, INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Wisconsin, Michigan, Iowa — Major
multispecialty groups and a staff model IIMO
are seeking additional physicians specializing
in family practice, internal medicine,
pediatrics, hematology/oncology, nephrology
and occupational medicine. Innovative,
growing practices in safe, progressive
communities. Choose from suburban and
metropolitan cities, college and resort towns
rural destinations. Enjoy four distinct season
and an abundance of recreation at pristine
lakes and forests. For more information, call
Strelcheck & Associates at 800/243-4353.
IM Board Review
Excellent passing record
San Diego, CA 2-17 to 2-21-96
St. Louis, MO 4-10 to 4-14-96
Newark , NJ 6-26 to 6-30-96
Columbus, OH 7-31 to 8-4-96
Voice mail 614/631-2756
Write to IMBRC
5892 Whitestone
Columbs, Ohio 43228
496 Iowa Medicine Volume 85/ 12 December 1995
CLASSIFIED ADVERTISING
Ffl
Floyd Valley Hospital
U
C3
s
Seeking quality primary care
trained or emergency medicine
physician to practice at FVH.
• 4300 average volume ER
• Medical director and staff posi-
tions
• Full-time, regularpart-timeand
moonlighting opportunities
• Weeknight, 12-hour shifts and
weekends
• Highly competitive salary
• Paid St. Paul malpractice
Send CV or contact
1 Melissa J. Milliken, CMSC
■ggggpp
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A ACUTE CARE, INC.
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Hsosasaa,'.
^gPaaaaaarj-.:i
' PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Family Practitioner — McFarland Clinic is
actively recruiting a BE/BC family practice
physician to assume the responsibilities of an
established family medicine practice in central
Iowa. Practitioner has support of over 80
medical and surgical sub-specialty physicians
in same multispecialty group. Full privileges
for a residency-trained family physician at
Mary Greeley Medical Center, a 200-bed
hospital in Ames, Iowa. Night call on a
rotating basis at the Emergency Room at
MGMC. McFarland Clinic offers distinct
advantages for the practicing physician in
providing excellent compensation and
benefits, practice management services and a
generous retirement program, all in an
environment which emphasizes physician
cooperation and teamwork. For additional
information, call or submit CV to Karen
Andersen, 515/239-4535, McFarland Clinic,
P.C., 1215 Duff Avenue, Ames, Iowa 50010.
Ambulatory Care
Clinic
Seeking quality physician to prac-
tice either part, full-time or moon-
lighting during residency.
• Primary care, urgent care, oc-
cupational and sports medicine
• Weekday, weeknight and week-
end shifts
• Paid St. Paul malpractice
• Excellent benefit/bonus packages
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE , INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
Internal Medicine and Family Practice
ji Opportunities — Rural lake country commu-
nity is seeking the above practitioners to join
an active 13-physician multispecialty group.
Quality, comfortable living environment,
multiple recreational activities, fine educa-
tional opportunities and cultural activities
abound. Opportunity includes relaxed call,
1 liberal salary and exceptional benefits. Send
curriculum vitae or inquiries to Lake Region
Clinic, PC, Attn: Joel Rotvold, PO Box 1100,
Devils Lake, North Dakota 58301 or call 800/
648-8898 for further information.
C3
X
HI
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QJ
55
%
a
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Acute Care
Anesthesia Services, LC
Recruiting MD/DO
Anesthesiologists & CRNAs
• Professionally rewarding,
equitable anesthesia practices
• Full-time and part-time
• Incentive-based compensa-
tion and benefits — including
St. Paul medical professional
liability insurance
Send CV or contact
Melissa J. Milliken, CMSC
ACUTE CARE, INC.
PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
STORM LAKE. IOWA
Rural lakeside community provides unique
setting for self-styled family practice. Em-
ployment with clinic foundation owned by
county hospital means no buy-ins, 1:9 call
coverage with weekend ER relief coverage,
full employment contract with guarantee
and excellent benefit package. You deter-
mine what patients to hand off in an outpa-
tient hospital based referral system ot 25
specialists. A+ schools, A+ recreations and
A+ amenities. Send GV or call Darrell
Pritchard, Administrator, Buena Vista
Clinic, Box 742, Storm Lake, Iowa 50588;
collect 712/732-5012; fax 712/732-2538.
Orthopaedic Surgeon/Urologist
Clinton, Iowa
Join our 32-physician multispecialty group partner-
ship with a newly expanded, modern 70,000 square
feet office. Group established and thriving 29
years. Strong referral base and excellent industrial
base and support. Compensation competitive.
Positions also in Michigan and Effingham, IL.
For information on these and other specialties
opportunities available nationwide contact:
Avionne Allen
Physician's Placement Management Group
1000 Blythwood Place, Suite C-199
Davenport, Iowa 52804
800/251-6937 or fax 800/289-9754
Time For a Move?
BC/BE FP, IM, OB/GYN, PEDS
Our promise — Well save you valuable time by
calling every hospital, group and ad in your
desired market. You’ll know every job within
7 days. We track every community in the
country, including 2000+ mral locations. Cedar
Rapids, Des Moines, Quad Cities, Kansas City,
Boston, Chicago, Indianapolis, many more.
New openings daily — call now for details!
The Curare Group, Inc.
M-F 9am-8pm, Sat 1-5 pm EST.
800/880-2028, Fax 812/331-0659
.lob #( I 133.M.1
(Continued next page)
Advertising Rates and Data
Regular classified advertising sells for 82.00
per line with a 830 minimum per insertion.
For members of the Iowa Medical Society
the rate is 820 per insertion. Display
classified advertising sells for 825 per
column inch, per month. Sizes range from
1 column by 2 inches to 1 column by 6
inches. A variety of type sizes, borders,
reverses or screens can be included in the
ad. Blind box numbers are available upon
request at no additional charge. Copy
deadline is the 1st of the month preceding
publication. Send or fax copy to Iowa
Medicine, 1001 Grand Avenue, West Des
Moines, Iowa 50265-3599, fax 515/223-
8420.
Iowa Medicine Volume 85/ 12 December 1995 497
Iowa [Medicine
CLASSIFIED A D V E R T I S I N
Buena Vista
County Hospital
Seeking quality primary care
trained or emergency medicine
physician to practice at BVCH.
• Week night and weekend shifts
available
• Approximately 45-55 patient
volume per shift
• Highly competitive compensa-
tion
• Paid St. Paul malpractice
Send CV or contact
Ki Melissa J. Milliken, CMSC
;j ACUTE CARE, INC.
"■ ^PO Box 515, Ankeny, IA 50021
800/729-7813 or 515/964-2772
Fax 515/964-2777
INTERNIST . . .
Want to share call with eight other internists and live in the
Brainerd Lakes Area? Immediate and future openings
available at Brainerd Medical Center.
Brainerd Medical Center, P.A.
• 30-physician independent multispecialty group
• Located in a primary service area of 40,000 people
• Almost 100% fee-for-service
• Excellent fringe benefits
• Competitive compensation
• Exceptional services available at 162-bed local hospital
— St. Joseph’s Medical Center
Brainerd, Minnesota
• In the middle of the premier lakes of Minnesota
• Less than 2 1/2 hours from the Twin Cities, Duluth and
Fargo
• Large, very progressive school district
• Great community for families
Inquiries from general internists or internist with subspecialty
interest in pulmonology or rheumatology welcomed.
Call collect to administrator:
Curt Nielsen
Brainerd Medical Center, P.A.
218/828-7105 or 218/829-4901
2024 South 6th Street, Brainerd, Minnesota 56401
FAMILY PRACTITIONER . . .
Want to share call with 11 other family practitioners and
live in the Brainerd Lakes Area? Immediate and future
openings available at Brainerd Medical Center.
Brainerd Medical Center, P.A.
• 30-physician independent multispecialty group
• Located in a primary service area of 40,000 people
• Almost 100% fee-for-service
• Excellent fringe benefits
• Competitive compensation
• Exceptional services available at 162-bed local hospital
— St. Joseph’s Medical Center
Brainerd, Minnesota
• In the middle of the premier lakes of Minnesota
• Less than 2 1/2 hours from the Twin Cities, Duluth and
Fargo
• Large, very progressive school district
• Great community for families
Call collect to administrator:
Curt Nielsen
Brainerd Medical Center, P.A.
218/828-7105 or 218/829-4901
2024 South 6th Street, Brainerd, Minnesota 56401
EMERGENCY MEDICINE
Iowa
North & Central Minnesota
Q Full- and part-time
Q Comprehensive benefit packages
Q Paid malpractice
Q Professional environments
Ample time for family and leisure
Progressive physician-owned group
Q Excellent compensation packages
Q Various locations
Q Reasonable housing in safe
communities
^ Top-notch school systems
Q Quality lifestyles
Call 1-800 458-5003
Emergency Practice Associates
or send CV to Sheila Jorgensen
P.O. Box 1260, Waterloo, IA 50704
498 hmn Medicine Volume 85 / 12 December 7995
Yes, you should get involved!
Educational materials created by the IMS Task Force on
Domestic Violence are now in use across Iowa and are getting
excellent reviews from people inside and outside the medical
profession. These materials, available to any IMS member,
include:
•A 27-minute commonsense video aimed at physicians but using an
interdisciplinary approach to solutions.
•A handbook appropriate for use in your office as a one-stop source of
practical information on identifying and managing victims of domestic
abuse. Includes information on getting a restraining order and docu-
menting abuse.
•Posters for your exam rooms or reception area.
•Hotline cards containing the IMS domestic violence logo and the
statewide domestic violence hotline.
To get materials or to learn more about the IMS campaign
against domestic abuse, call Chris McMahon at the IMS, 515/223-
1401 or 800/747-3070.
RUN A SPECIAL
PRACTICE.
Today’s Air Force has special opportuni-
ties for qualified physicians and physi-
cian specialists. To pursue medical excel-
lence without the overhead of a private
practice, talk to an Air Force medical pro-
gram manager about the quality lifestyle,
quality benefits and 30 days of vacation
with pay each year that are part of a
medical career with the Air Force. Dis-
cover how special an Air Force practice
can be. Call
USAF HEALTH PROFESSIONS
TOLL FREE
1-800-423-USAF
Iowa|Medicine
Professional Listing
Allergy
Electrodiagnosis
Family Practice
John A. Caffrey, Ml), PC
1212 Pleasant, Suite 106
Des Moines 50309
515/243-0590
Allergy & Immunology
Allergy Institute, PC
A.Y. Al-Shash, MI)
K.K. Agarwal, MD
1701 22nd Street, Suite 201
West Des Moines 50266
515/223-8622
Pediatrie and Adult Allergy, PC
Veljko K. Zivkovieh, MD
Robert A. Column, MD
1212 Pleasant, Suite 110
Des Moines 50309
515/244-7229
Asthma, Allergy & Immunology
John Milner-Brage, MD
2710 St. Francis Drive, Suite 208
Waterloo 50702
319/234-6446
Electromyography & Nerve
Conduction Studies
Certified by American Board of
Electrodiagnostic Medicine
Emergency Medicine
Acute Care, Ine.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Comprehensive Emergency Medicine
Practice, Locum Tenens,
Doctor on Call
Acute Care, Inc.
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Locum Tenens
Doctor on Call
Infectious Diseases
Chest, Infectious Diseases & Critical Car
Associates, PC
Daniel II. Gcrvich, MD
Daniel J. Schrocdcr, MI)
Ravi K. Venturi, Ml)
Infectious Diseases
1601 NW 1 14th, Suite 347
Des Moines 50325-7072
24 Hours 515/224-1777
Anesthesiology
Acute Care Anesthesia Services, LC
P.O. Box 515
Ankeny 50021
515/964-2772 or 1-800/729-7813
Anesthesiologists and CRNAs
Dermatology
Robert J. Barry , MD
1030 Fifth Avenue, SE
Cedar Rapids 52403
319/366-7541
Practice Limited to Disease,
Cancer and Surgery of Skin
Fort Dodge Medical Center, PC
Carey A. Itligard, MI), FAAD
James I). Bunker, MI), FAAD
804 Kenyon Road
Fort Dodge 50501
515/574-6850
Emergency Practice Associates
P.O. Box 1260
Waterloo 50704
1-800/458-5003
Specialists in Emergency
Staffing & Emergency Department Services
Facial Plastic and Reconstructive
Surgery
Otologic Medical Services, PC
Guy E. McFarland, MD
Thomas F. Viner, MI)
Douglas E. Dawson, MD
Thomas A. Simpson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Satellite Clinics: Washington, Mt. Pleasant,
Muscatine, Fairfield and Leon
Infertility
Mid-Iowa Fertility, PC
Donald C. Young, DO
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Reproductive Endocrinology/Infertility
TVF and GIFT Procedures
Donor Oocyte Program
Artificial Inseminations
Reproductive Surgery
Menopause Management
500 Iowa Medicine Volume 85/ 12 December 1995
PROFESSIONAL LISTING
Internal Medicine
Fort Dodge Medical Center, 1*C
Cardiology
Samir G. Artoul, Ml), 1 ICC
515/574-6840
Gastroenterology
Kenneth W. Adams, DO, AOBIM
General Internal Medicine
William C. Robb, MD
Richard II. Rrandt, MI), AB1M
Grace Z. Ang, MD
800 Kenyon Road
Fort Dodge 50501
515/574-6820
Neurology
Iowa Medical Clinic Neurology
Andrew C. Peterson, MD
Laurence S. krain, Ml)
600 7 tli Street SE
Cedar Rapids 52401
319/398-1721
Neurology, EEG, EMG, Evoked Potentials
and Sleep Studies
Fort Dodge Medical Center, PC
Jugal T. Raval, MD, MBBS
800 Kenyon Road
Fort Dodge 50501
515/574-6845
Neurosurgery
Iowa Medical Clinic
Neurosurgery
James R. Lamorgcse, Ml)
Loren J. Mouw, MD
600 7th Street, SE
Cedar Rapids 52401
1 319/366-0481
Practice limited to Neurosurgery
Neurosurgical Services LLP
Robert Ilayne, MD
Thomas A. Carlstrom, MD
David J. Boarini, Ml)
1215 Pleasant, Suite 608
Des Moines 50309
515/241-5760
Robert C. Jones, MI)
S. Randy Winston, MI)
Douglas R. Koontz, MD
2600 Grand Avenue, Suite 210
Des Moines 50312
515/283-2217
Neurological Surgery >
Chad I). Ahcrnathcy, MD
1953 1st Avenue SE
Cedar Rapids 52402
319/363-4622
Neurological Surgery
llosung Chung, MD
2710 St. Francis Drive, Suite 401
Waterloo 50702
319/232-8756; fax 319/232-5703
Practice limited to Neurosurgery
Obstetrics/Gynecology
Fort Dodge Medical Center, PC
Brian L. Welch, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6870
Ophthalmology
Wolfe Clinic, PC
Russell II. Watt, MD
John M. Graether, MD
Gilbert \Y. Harris, MD
James A. Davison, MD
Norman F. Woodlief, MD
Erie IV. ltligard, MD
David I). Saggau, MD
Steven C. Johnson, MD
Todd W. Gothard, MD
309 East Church
Marshalltown 50158
515/754-6200
Satellite Offices
Lakeview Medical Park
6000 University Avenue, Suite 300
West Des Moines 50266
515/223-8685
804 South Kenyon Road, Suite 100
Fort Dodge 50501
515/576-7777
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-0103
214 - 13th Street Southeast
Cedar Rapids 52403
319/362-8032
Eye Physicians and Surgeons, LLP
Stephen 11. Wolken, MD
Robert B. Goffstein, MD
Lyse S. Strnad, MD
John F. Stamler, MD, PhD
540 E. Jefferson, Suite 201
Iowa City 52245
319/338-3623
North Iowa Eye Clinic, PC
Addison W. Brown, Jr., MD
Michael L. Long, MD
Bradley L. Isaak, MD
Randall S. Brcnton, MD
James L. Dummctt, MD
Mick E. Vanden Bosch, MD
3121 4th Street, S.W.
P.O. Box 1877
Mason City 50401
515/423-8861
Timothy F. Moran, Jr., MD
United Federal Building
700 4th Street, Suite 305
Sioux City 51101
712/252-4333
Satellite Clinics
Horn Memorial Hospital
700 E. 2nd Street
Ida Grove 51445
712/364-3311
Orange City Hospital
400 Central Avenue NW
Orange City 51041
712/737-2426
General Ophthalmology
Orthopaedics
Iowa Orthopaedic Center, PC
Marshall Flapan, MD
Sincsio Misol, MD
Joshua I). Kimclmnu, DO
Timothy G. Kenney, MI)
Lynn M. Lindaman, MD
Jeffrey M. Farber, MD
Kyle S. Gallcs, MD
Scott A. Meyer, MD
Cassini M. Igram, MD
Rodney E. Johnson, MI)
Martin S. Roscnfcld, DO
Teri S. Formanek, MD
Stephen M. Naruto, MD
Donna J. Balds, Ml>
Jill R. Meilahn, DO
Jacqueline M. Stokcn, DO
411 Laurel, Suite 3300
Des Moines 50314
515/247-8400
(Continued next page)
Professional Listing Rates
Physician members of the Iowa Medical
Society may advertise in this directory.
Monthly rates are as follows: S3. 00 per
line. Billed yearly. May be prorated.
Send or fax copy to Iowa Medical Society,
1001 Grand Avenue, West Des Moines,
Iowa 50265-3599, fax 515/223-8420.
Iowa Medicine Volume 85/ 12 December 1995 501
1U Wrt IIVICUIC IIIC
Orthopaedic Surgery
Fort Dodge Medical Center, PC
C. Mark Race, MI)
Entile C. Li, Ml)
800 Kenyon Road
Fort Dodge 50501
515/574-6880
Otolaryngology
Iowa ENT, PC
Thomas A. Iirieson, MD
Marshall C. Greiman, MI)
Steven R. Herwig, DO
Thomas O. Paulson, MD
Mark K. Zlah, MD
1-800/248-4443
1215 Pleasant, Suite 408
lies Moines 50309
515/241-5780
1200 35th Street, Suite 200
West Des Moines 50266
515/225-7761
Satellite Clinics:
Pella, Perry, Newton , Indianola,
Oskaloosa, Guthrie Center, Knoxville
Robert G. Smits, MD, PC
1040 5th Avenue
Des Moines 50314
515/244-8152
1-800/622-0002
Ear, Nose and Throat Surgery,
Facial Plastic Surgery > and Head and
Neck Surgery
Wolfe Clinic, PC
Michael W. Dili, MD
Daniel J. Blum, MD
309 East Church
Marshalltown 50158
515/752-1566
Lakeview Medical Park
6000 University Avenue, Suite 310
West Des Moines 50266
515/224-9533
Sartori Professional Building
516 South Division Street
Cedar Falls 50613
319/277-3105
Otolaryngology-Head and Neck Surgery,
Facial Plastic Surgery, Allergy
Iowa Head and Neck Associates, PC
Robert T. Brown, MD
Eugene Peterson, MD
Richard B. Merrick, MI)
Peter V. Boesen, MD
Robert R. Updcgraff, MI)
3901 Ingersoll
Des Moines 50312
515/274-9135
Otologic Medical Services, PC
Guv E. McFarland, Ml)
Thomas F. Viner, MD
Douglas E. Dawson, Ml)
Thomas A. Simpson, MD
540 E. Jefferson, Suite 401
Iowa City 52245
319/351-5680
1-800/642-6217
Maxillofacial, Plastic, Head & Neck
Surgery
Satellite Clinics: Washington, Mt. Pleasant,
Muscatine, Fairfield and Leon
Phillip A. Linquist, DO, PC
1000 Illinois
Des Moines 50314
515/244-5225
Ear, Nose and Throat Surgery’,
Facial Plastic Surgery, Head
and Neck Surgery
Duhuquc Otolarvngology-Head & Neck
Surgery, PC
Thomas .1. Benda, Sr., MD
Janies YV. YYliitc, MD
Craig C. Ilcrthcr, MD
Thomas J. Benda, Jr., MD
310 North Grandview Avenue
Dubuque 52001
319/588-0506
Pain Management
Iowa Medical Clinic Outpatient Pain
Treatment Center
James R. LaMorgcse, Ml), FACS,
Neurosurgeon, Medical Director
Sandra Gannon, LSYY’, ACSYV, Program
Director
600 7th Street SE
Cedar Rapids 52401
319/399-2013
Neurology, Psychiatry, Anesthesiology,
Rheumatology
Pediatrics
Fort Dodge Medical Center, PC
Ronald C. Sanders, MD
Rosana M. Diokno, MI)
800 Kenyon Road
Fort Dodge 50501
515/574-6855
Perinatology
I)cs Moines Perinatal Center, PC
Neil T. Mundsagcr, MD
3408 Woodland Avenue, Suite 302
West Des Moines 50266
515/222-3060
Maternal-Fetal Medicine
Routine and Advanced (Level II)
Obstetric Ultrasound
Genetic Counseling
Amniocentesis and CVS
Antenatal Testing
High-Risk Obstetrical Management
High-Risk Deliveries
Physical Medicine &
Rehabilitation
Rehabilitation Medicine Associates
Younker Rehabilitation Center
1200 Pleasant
lies Moines 50308
515/241-6434
2600 Grand Avenue, Suite 102
Des Moines 50312
515/283-1570
Genesis Regional Rehabilitation Center
Genesis Medical Center
1227 East Rusholme Street
Davenport 52803
319/383-1466
Maurice D. Schncll, MD
Farccduddin Ahmed, Ml)
Arthur B. Scarlc, MD
Bogdan E. Krvsztofiak, MD
Pulmonary Medicine
Fort Dodge Medical Center, PC
Robert C. Ang, MD, FCCP
800 Kenyon Road
Fort Dodge 50501
515/574-6820
502 Iowa Medicine Volume 85/ 12 Deccmmber 19 95
HEALTH SCIENCES LIBRARY
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